Journal of Oral Science & Rehabilitation No. 1, 2016

Journal of Oral Science & Rehabilitation No. 1, 2016

Cover / Editorial / Contents / About / Identification of Staphylococcus aureus at the internal and external implant surfaces in individuals with periimplant disease: A cross-sectional study / Influence of the position of implants placed immediately into extraction sockets: An experimental study in dogs / Clinical and histological evaluation of a flapless socket preservation procedure: A prospective single cohort study / Review of the arterial vascular anatomy for implant placement in the anterior mandible / Transcrestal sinus floor elevation performed twice with collagen sponges and using a sonic instrument / Primary stability of dental implants with different thread geometries placed by clinicians with different clinical experience: An in vitro study / The coronally advanced flap in the treatment of bilateral multiple gingival recessions with or without tunneling the maxillary midline papilla: A randomized clinical trial / Five-year esthetic evaluation of implants used to restore congenitally missing maxillary lateral incisors after orthodontic space opening treatment / Authors must adhere to the following guidelines / Imprint

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Journal of

Oral Science
&
Rehabilitation
Volume 2 — Issue 1/2016

ISSN 2365-6891

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

[2] => U1_Cover_A4_ePaper.qxp_Layout 1

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[3] => U1_Cover_A4_ePaper.qxp_Layout 1

00_JOSR_A4_Editorial.qxp_Layout 1 02.03.16 16:13 Seite 1

Editorial

Journal of

Oral Science
&
Rehabilitation
The two twin souls of research

In an ideal world, research in general, and dental research in particular, would answer all of the questions a clinician would formulate
in order to better treat the final beneficiary of the research itself,
the patient. Our journal has been designed from the very beginning
to consider foremost the patient. In order to achieve this, several
groups of researchers were invited to form part of the journal
board, each group being represented by a clinician, whom I would
call the “clinical soul” of the group.
However, clinical protocols alone can be interpreted in many different ways, even incorrectly, if not approached with the requisite
background knowledge. In order to be able to yield a scientifically
meaningful answer, clinical protocols must be validated under the
supervision of highly trained researchers. For this reason, all of the
groups that joined the journal constitute also an “analytic soul,” in
order to establish the methodology, lead the clinical study and
interpret the results.
The two components of research, which I would call the two “souls
of research,” are linked to one another. Underestimating the importance of one of these two components, one of these two souls, or
leaving one of them out would lead to an impoverishment of the
value and benefit of any research results and therefore to the
established goal remaining unfulfilled.
Dr. Luigi Canullo
Associate Editor

Journal of
Oral Science & Rehabilitation

Volume 2 | Issue 1/2016

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Contents

03
Editorial
Dr. Luigi Canullo
06
About the Journal of Oral Science & Rehabilitation
08
Luigi Canullo et al.
Identification of Staphylococcus aureus at the internal and external implant
surfaces in individuals with periimplant disease: A cross-sectional study
14
Enzo De Santis et al.
Influence of the position of implants placed immediately into extraction
sockets: An experimental study in dogs
22
Valentina Borgia et al.
Clinical and histological evaluation of a flapless socket preservation
procedure: A prospective single cohort study
32
José Carlos Balaguer Marti et al.
Review of the arterial vascular anatomy for implant placement in the
anterior mandible
40
Ivo Agabiti & Daniele Botticelli
Transcrestal sinus floor elevation performed twice with collagen sponges
and using a sonic instrument
48
Rafael Arcesio Delgado Ruiz et al.
Primary stability of dental implants with different thread geometries placed
by clinicians with different clinical experience: An in vitro study
56
Roberto Abundo et al.
The coronally advanced flap in the treatment of bilateral multiple gingival
recessions with or without tunneling the maxillary midline papilla:
A randomized clinical trial
62
Alessandro Mangano et al.
Five-year esthetic evaluation of implants used to restore congenitally
missing maxillary lateral incisors after orthodontic space opening treatment
72
Guidelines for authors
74
Imprint— about the publisher

04 Volume 2 | Issue 1/2016

Journal of
Oral Science & Rehabilitation

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Nobel Biocare Global Symposium
June 23–26, 2016 – New York

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[6] => U1_Cover_A4_ePaper.qxp_Layout 1

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 2 | Issue 1/2016

Journal of
Oral Science & Rehabilitation

[7] => U1_Cover_A4_ePaper.qxp_Layout 1

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.
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www.dtscience.com and www.dental-tribune.com.
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a webinar and blog on www.dtscience.com.

Subscription price
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Information for subscribers
The journal is published quarterly. Each issue is published as both a print
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Copyright © 2016 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.

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Staphylococcus aureus and periimplant disease

Identification of
Staphylococcus aureus at
the internal and external
implant surfaces in individuals
with periimplant disease:
A cross-sectional study
Abstract
Objective
Luigi Canullo,*
Paulo Henrique Orlato Rossetti,†
Marco Tallarico*
& David Peñarrocha Oltra‡

The objective of this study was to investigate the prevalence of
Staphylococcus aureus (S. aureus) at internal and external dental
implant surfaces in patients with periimplant disease.

*

Independent researcher, Rome, Italy
Independent researcher, Bauru, Brazil
‡
Oral Surgery Unit, Department of Stomatology,
Faculty of Medicine and Odontology,
University of Valencia, Valencia, Spain

Materials and methods

†

Corresponding author:
Dr. Luigi Canullo
Via Nizza 46
00198 Rome
Italy

Samples for microbiological analysis were obtained from four types
of sites in the following order: (1) the periimplant sulcular ﬂuid (PISF)
of each implant; (2) the gingival sulcus (GS) of the adjacent teeth; (3)
the implant–abutment connection and abutment inner portions (IIP)
of each implant; and (4) the oropharyngeal complex (OF)—oral,
tongue and pharynx swabs were also collected.
Quantitative real-time polymerase chain reaction assays were
carried out for total bacterial counts. The Kruskal–Wallis test was
used to compare the S. aureus levels at the various sites.

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

Results

How to cite this article:
Canullo L, Orlato Rossetti PH, Tallarico M,
Peñarrocha Oltra D. Identification of Staphylococcus
aureus at the internal and external implant surfaces
in individuals with periimplant disease:
a cross-sectional study.

Mean bacterial counts of S. aureus were as follows: GS = 5.02 × 102;
PISF = 0, IIP = 0 and OF = 0. A positive value was found for one out of
the 35 sites for each group, but under the limit of quantiﬁcation. For
GS, one out of the 35 sites presented with a total bacterial count of
2.11 × 104. No statistically signiﬁcant differences were found among
groups regarding site location (p = 0.40).
Conclusion

J Oral Science Rehabilitation.
2016 Mar;2(1):8–13.

Within the limits of this study, S. aureus could not be quantiﬁed in the
PISF and inside the IIP affected by periimplantitis.
Keywords

Periimplantitis, periimplant disease, microbiological analysis,
opportunistic pathogens, implant connection, S. aureus.
08 Volume 2 | Issue 1/2016

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Staphylococcus aureus and periimplant disease

Introduction
Dental implantology is a central part of modern
dentistry concerned with the replacement of
missing teeth in various clinical situations. In the
past 30 years, the materials and methods of implant dentistry have undergone a substantial
process of development and evolution. Implant
surface, macrodesign and type of implant–
abutment connection have been found to be of
major relevance to initial healing and long-term
stability.1–3 Since the number of implants placed
has increased in the last ten years, optimal maintenance has become increasingly important.4, 5
While in many cases, it has been reported that
dental implants are a safe and predictable treatment method with high survival rates, they are
not immune from biological and iatrogenic complications associated with improper treatment
planning, surgical and prosthetic execution, or
material failure, as well as maintenance problems.5 Also, the biological complications of periimplant mucositis and periimplantitis, which
may result in soft- and hard-tissue defects, have
been suggested to be relevant for later marginal
bone loss.6
Several approaches have been followed in
seeking to understand the pathomechanism of
periimplantitis. According to a consensus conference of the American Academy of Periodontology, bacterial colonization of the implant surface and the occurrence of bone loss indicate the
point of no return in periimplantitis.7 Periimplantitis is characterized by an inﬂammatory process
around an implant that includes both soft-tissue
inﬂammation and progressive loss of periimplant supporting bone. Periimplantitis occurs
primarily as a result of overwhelming periodontal insult and subsequent immune response.7
The connection to periodontitis as an infectious
disease with comparable symptoms and outcomes suggests that investigating the associated local bacteria is fundamental to establishing
the pathomechanism of periimplantitis.
The implant surface may be colonized with
different pathogens other than periodontal bacteria.8 According to Albertini et al., opportunistic
pathogens such as Pseudomonas aeruginosa,
Staphylococcus aureus (S. aureus) and Candida
albicans may be associated with implant failure.9
As suggested in an American Academy of
Periodontology report, secondary diagnostic
measures, that is, bacterial culturing, inﬂammatory markers and genetic factors, may be useful

in the diagnosis of periimplant disease.7 According to Canullo et al., bacterial agglomerates
around dental implants and their prosthodontic
adjacent structures have been identiﬁed.10
These results suggested that all of the connections were contaminated after ﬁve years of functional loading; thus, the implant–abutment connection design might inﬂuence bacterial activity
levels qualitatively and quantitatively, especially
inside the implant connection.10 Furthermore,
Cosyn et al. found that intracoronal compartments of screw-retained ﬁxed restorations were
heavily contaminated.11 Further investigations
have shown that the restorative margin is the
principal pathway for bacterial leakage and contamination of abutment screws, and bacteria
most likely pass from the periimplant sulcus
through the implant–abutment and abutment–
prosthesis interfaces.10
With the aim of identifying the pathogens
that contribute toward the development of periimplantitis defects, different working groups
have reported a cluster of bacteria, including
Treponema forsythia and S. aureus, associated
with periimplant disease.12
The presence of S. aureus as an opportunistic
pathogen in the early stage of active periimplantitis in patients has also been conﬁrmed by
Mombelli and Décaillet.13 In addition, Salvi et al.
reported that detection or lack of S. aureus at implant sites at 12 weeks resulted in the highest
positive (i.e., 80%) and negative (i.e., 90%) predictive values for the incidence of periimplantitis,
respectively.14 Moreover, Canullo et al. showed
that S. aureus is present on the external and internal abutment surfaces if these are not cleaned
before screwing.15
The aim of the present study is to investigate
the prevalence of S. aureus in the oral cavity of patients with active periimplantitis. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.16

Materials & methods
Study design

This cross-sectional study evaluated data collected from 51 consecutive, partially edentulous
patients of both sexes, aged 18 or older (mean
age of 54.2), who had been treated with a single
implant-supported, cemented or screw-retained
restoration functionally loaded for at least 12

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Staphylococcus aureus and periimplant disease

months, with adjacent healthy teeth, but presenting signs of periimplant disease according to
Mombelli and Décaillet.13 The patients were invited to participate and were enrolled after being
given a detailed explanation of the study protocol. Written informed consent was obtained for
each patient. All of the patients were recruited
from the Department of Oral Surgery, University
of Valencia, Spain, between September and December 2013. The investigation was conducted
according to the principles outlined in the Declaration of Helsinki of 1975 for biomedical research
involving human subjects, as amended in 2008.
All patients were evaluated clinically and radiographically, and their medical histories were
recorded. Bone volumes were analyzed using
periapical radiographs.
The inclusion criteria were:
– presence of periimplant disease with a vertical
bone defect of > 3 mm after implant integration according to Mombelli and Décaillet13
– age > 18
– no relevant medical conditions.
The exclusion criteria were:
– pregnancy or lactation
– known systemic disease or metabolic disorders (e.g., HIV) treated with medication detrimental to soft tissue and/or bone healing (e.g.,
high-dose steroid therapy, systemic treatment
with tetracycline or tetracycline analogs, bone
therapeutic levels of ﬂuorides, bisphosphonates, medication affecting bone turnover, antibiotics for more than seven days or any investigational drug)—topical application of steroids
and steroid application through inhalation
were not exclusion criteria
– malignant diseases or other diseases treated
with radiotherapy or chemotherapeutic agents
(chemotherapy) during the past ﬁve years
– a history of head and neck radiation treatment
owing to certain medical conditions
– a suspected allergy or incompatibility with any
of the bone graft substitute components (calcium phosphates, PLGA, NMP)
– inability to comply with the protocol requirements, including severe alcohol or drug user
– involvement in any other clinical trial during the
course of the present trial, or within a period of
30 days prior to its beginning or after its completion
– acute abscesses localized in the proximity of
the prospective surgical ﬁeld.
10 Volume 2 | Issue 1/2016

After full screening, 16 patients were to be excluded: 13 had taken systemic antibiotics during
the three months prior to the microbiological
sampling, two were pregnant, and one refused to
participate. The ﬁnal sample consisted of 35 individuals (20 male, 15 female) and 63 affected
dental implants.
Microbiological sampling

Samples for microbiological analysis were obtained from four sites in each patient in the following order: (1) the periimplant sulcular ﬂuid
(PISF) of each implant; (2) the gingival sulcus
(GS) of the adjacent teeth, used as control group;
(3) the inner portions of the implant connection
and the abutment of each implant (IIP); and (4)
the oropharyngeal complex (OF). In all of the
groups, the microbiological samples were taken
using the GUIDOR Perio-Implant Diagnostic Kit
(Sunstar Iberia, Sant Just Desvern, Spain), consisting of ﬁve sterile absorbent paper tips and an
empty sterile 2 ml microtube.
Prior to collection of the subgingival plaque,
supragingival plaque was eliminated from implants and teeth using a cotton tip, without penetrating the GS. OptraGate (Ivoclar Vivadent,
Schaan, Liechtenstein) was used to retract the
lips and cheeks completely and to ensure relative isolation. After light drying of the area with
an air syringe, paper tips were inserted into the
periimplant or periodontal sulci for 30 s. The
samples from the inner surfaces of the implant–abutment complex were obtained after
careful removal of both the restorations and
the abutments, seeking to avoid contamination. One drop of RNA- and DNA-free water
(Water Molecular Biology Reagent, W4502,
Sigma-Aldrich, St. Louis, Mo., U.S.) was placed
inside the implant connection and three paper
tips were inserted for 30 s. The inner surface of
the abutment was wet with a drop of RNA- and
DNA-free water and smeared with two paper
tips. The paper tips were placed into the microtubes and sent for microbiological analysis to
the Institut Clinident laboratory (Aix-enProvence, France) in the provided mailing envelopes. Finally, an oral environment analysis
was performed using sterile cotton swabs collected from the cheeks, tongue, throat and
pharynx of each patient.
After sample collection, the inner part of
the implants and the abutment–restoration
complex were cleaned with a 5% chlorhexidine

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Staphylococcus aureus and periimplant disease

Table 1

Sites

Positive sites/
number of sites

TBC

Mean
bacterial counts

1/35

2.11 × 104

PISF

1/35

IIP

1/35

1 positive case, but below
level of quantiﬁcation
1 positive case, but below
level of quantiﬁcation
1 positive case, but below
level of quantiﬁcation

5.02 × 102
0
0
Table 1

Investigated sites and
bacterial counts.

GS: gingival sulcus of the adjacent teeth; PISF: periimplant sulcular ﬂuid; IIP: inner parts of connection; OF: oropharyngeal complex.

solution in an ultrasonic bath for 10 min. Afterward, a new abutment screw was connected
using a torque wrench (Torq Control, Anthogyr,
Sallanches, France) until it reached a torque of
30 N cm, according to the manufacturer’s instructions. In order to verify proper fit between
the dental restoration and the implant, standardized digital periapical radiographs were
taken using a dental radiographic film holder
(Rinn Centrator Bite, DENTSPLY RINN, Elgin,
Ill., U.S.) and the paralleling technique.

Statistical analysis

The mean and standard deviations for TBCs at
each inspected site (PISF, GS, IIP, OF) were
recorded and analyzed according to a pre-established analysis plan. A bio-statistician with expertise in dentistry analyzed the data using statistical software (SigmaPlot, Version 13, Systat
Software, San Jose, Calif., U.S.). Before running
the statistical analysis, the TBCs for each site
were transformed (log transformation [log10]) in
an attempt to render less skewed distributions,
Quantitative real-time
making the data more interpretable and helping
polymerase chain reaction assays
to meet the assumptions of inferential statistics.
As the normality test failed, a nonparametric test
Quantitative real-time polymerase chain reac- (Kruskal–Wallis) was used. The level of signiﬁtion (PCR) assays were carried out for total bac- cance was set at α = 0.05.
terial counts (TBCs) for each target species,17, 18
in a volume of 10 μL composed of 1× QuantiFast
SYBR Green PCR (Qiagen, Hilden, Germany),
Results
2 μL of DNA extract, and 1 μM of each primer.
The species-specific PCR primers used in this No implants were lost, and all of the prostheses
study were provided by Institut Clinident and were in situ at the time of examination. At the end
manufactured by metabion (Martinsried, Ger- of the study, just one site (out of 35) in the GS of the
many). Assays were carried out on the Rotor- adjacent teeth presented a TBC of 2.11 × 104. The
Gene Q thermal cycling system (Qiagen) with mean bacterial count of S. aureus was 5.02 × 102;
the following program: for TBC, 95 °C for 30 s, therefore, this value was taken as control. Confollowed by 40 cycles of 10 s at 95 °C, 10 s at versely, in the PISF of each implant, the IIP and
60 °C, and 35 s at 72 °C; for S. aureus, 95 °C for the OF complex, the mean bacterial counts of
5 min, followed by 40 cycles of 10 s at 95 °C, S. aureuswere 0, with only one site (out of 35) pos10 s at 66 °C, and 35 s at 72 °C. A final melting itive, but below the level of quantiﬁcation. The
curve analysis (70–95 °C in 1 °C steps for 5 s in- data are reported in Table 1. No statistically signiﬁcrements) was performed. Fluorescence sig- cant differences were found among groups
nals were measured every cycle at the end of regarding site location (Kruskal–Wallis test;
the extension step and continuously during the p = 0.40).
melting curve analysis. Serial dilutions of standard DNA, provided by Institut Clinident, were
Discussion
used in each reaction as external standards for
absolute quantification of the target pathogen.
Finally, the data were analyzed using Rotor- Currently, there are neither standardized antibiotic
prophylactic regimens for dental implant placeGene Q Series Software (Qiagen).
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Staphylococcus aureus and periimplant disease

ment nor universally accepted treatment for periimplantitis. The treatment of infected implants is
difﬁcult and usually requires removal.18 However,
it has become clear that therapy of periimplant
mucositis should be considered a preventive
measure for the onset of periimplantitis. Completion of active periodontal therapy should precede
implant placement in periodontally compromised
patients.19
S. aureus is a facultative coccus and Gram-positive bacterium normally associated with surgical
wounds in orthopedic patients.20 Part of this can
be explained by the impedance seen on cultured
osteoblasts, with S. aureus surviving up to 48 h
after internalization by those bone cells and
still eliciting interleukin 6 and interleukin 8 responses,21 which have pro-inﬂammatory effects
and are involved in osteoclastogenesis22 and foreign body reactions.23 In addition, S. aureus has
the ability to form a bioﬁlm and lead to chronic
infection.24
A retrospective study has demonstrated that
patients capable of maintaining high immunoglobulin G antibody titers to S. aureus had successful implants compared with nonosseointegrated ﬁxtures.25
In the present study, the lack of signiﬁcance
regarding the bacterial counts of S. aureus at IIP
and PISF must be considered, since in vitro this
pathogen has shown an afﬁnity for titanium surfaces,26 and two studies have related its levels to
deep periimplant pockets with bleeding on probing.27, 25 One study has demonstrated that the
bacterial counts of S. aureus increase from 5% to
15% at implant sites 12 weeks after surgery.28
However, another study pointed out that even
after seven years of follow-up the presence of
S. aureus at tooth sites could be indicative of the
presence of the same pathogen at implant
sites,25 while another study indicated that the
lack of S. aureus at implant sites after 12 weeks
demonstrated a high negative predictive value
after 12 months.29 More recently, an article
demonstrated that regardless of health status,
periodontal and periimplant sites harbored
S. aureus cells, being the highest load of all six
species analyzed.30

12 Volume 2 | Issue 1/2016

Conclusion
Within the limits of this study, S. aureus could not
be quantiﬁed inside and around dental implants
in detectable limits. However, clinicians must
bear in mind that, in the early stage of healing,
this pathogen can influence the immune response and lead to periimplant bone loss.

Competing interests
The study was supported by Sweden & Martina
(Due Carrare, Italy), which paid for the kits, and by
the Institut Clinident, which performed the
analysis free of charge. The authors declare that
they have no competing interests related to this
study.

Acknowledgments
The authors highly appreciate the skills and commitment of Dr. Audrenn Gautier in the supervision of the study. Additionally, the authors wish
to offer their gratitude to the Institut Clinident for
their professional support in the microbiological
analysis.

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plaque control protocols in the
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Galluccio F, Canullo L. Microbial leakage at
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2014 Nov 14. doi:10.1111/clr.12508.
[Epub ahead of print].

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2001 Oct;24(4):365–9.
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Jenkinson HF. Differential interactions of
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2013 Aug;28(4):250–66.
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JM, Smith RL. What are the local and
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[Epub ahead of print].
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Implant positioning within extraction sockets

Influence of the position of
implants placed immediately
into extraction sockets:
An experimental study in dogs
Abstract
Enzo De Santis,* Luiz A. Salata,†
Flávia Priscila Pereira,‡ Sara Ferraris,§
Fabio Pantani,** Giacomo Favero††
& Daniele Botticelli‡‡
*

Ariminum Research and Dental Education Center,
Ariminum Odontologica, Rimini, Italy
†
Ribeirão Preto School of Dentistry, University of
São Paulo, São Paulo, Brazil
‡
Faculdade de Odontologia de Araçatuba, Universidade Estadual Paulista, Araçatuba, Brazil
§
Institute of Materials Physics and Engineering,
Department of Applied Science and Technology,
Politecnico di Torino, Turin, Italy
**
Private practice, San Marino, Republic of
San Marino
††
Faculty of Dentistry, University of Medical Science,
Havana, Cuba
‡‡
Ariminum Research and Dental Education Center,
Ariminum Odontologica, Rimini, Italy; Faculdade
de Odontologia de Araçatuba, Universidade
Estadual Paulista, Araçatuba, Brazil; Faculty of
Dentistry, University of Medical Science, Havana,
Cuba; Programa Odontológico Internacional,
Cartagena de Indias, Colombia

Corresponding author:
Dr. Daniele Botticelli
Programa Odontológico Internacional
Av. Venezuela CL 35 CR 8B-05
Edificio Citibank
Piso 5, Oficina 5G
Cartagena de Indias
Colombia

Objective

The objective of this study was to evaluate the inﬂuence of implant
positioning within an extraction socket on the depth of the implant at
the time of surgery and on the buccal supracrestal exposure of the
implant surface after healing.
Materials and methods

Eight Labrador dogs were used. Their fourth mandibular premolars
were ﬁrst hemisectioned and the distal roots removed. The distal
alveoli were subsequently prepared bilaterally at the apex for implant placement. The implants were placed tilted either in contact
with the buccal (buccal position; B-sites) or the lingual (lingual position; L-sites) walls of the alveoli. After four months, biopsies were
collected and processed for histomorphometric analysis.
Results

The implants were found to be approximately 1 mm deeper at the
L-sites than at the B-sites. At the buccal aspect, a vertical resorption
of 1.6 ± 1.9 mm at the B-sites and of 0.4 ± 0.7 mm at the L-sites was
observed. The absolute vertical lingual bone resorption was
0.6 ± 0.5 mm and 0.7 ± 0.4 mm at the B- and L-sites, respectively.
The percentage of bone-to-implant contact was similar at both sites,
as well as buccolingually, and ranged between 31.2% and 35.2%.
The width of the buccal bony ridge was larger at the L-sites compared with the B-sites. The periimplant mucosa was wider and located more coronally at the L-sites compared with the B-sites.
Conclusion

T & F + 57 5 646 8359
M
+57 300 283 5720
daniele.botticelli@gmail.com

How to cite this article:
De Santis E, Salata LA, Pereira FP, Ferraris S, Pantani F,
Favero G, Botticelli D. Influence of the position of
implants placed immediately into extraction sockets:
An experimental study in dogs.

At implants placed immediately into extraction sockets, smaller
buccal exposure above the bone crest occurred when they were
placed tilted lingually instead of buccally. The implants placed lingually resulted in a deeper position within the extraction socket
compared with those placed buccally.
Keywords

Animal study, bone healing, extraction socket, defect, implant dentistry, osseointegration, histology, IPIES.

J Oral Science Rehabilitation.
2016 Mar;2(1):14–21.

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Implant positioning within extraction sockets

Introduction

Materials & methods

After tooth extraction, the immediate placement
of an implant into an alveolus is considered a predictable procedure, even though a higher loss of
implants has been reported.1 Moreover, it has
been shown that an implant placed into an extraction socket will not avoid bone resorption at
the coronal aspect of the walls of the alveolus.2, 3
One of the most important aspects to be considered is the position of the implant within the
extraction socket in relation to the buccolingual
walls of the alveolus. It has been shown that a
buccal placement will produce, after healing,
higher supracrestal exposure of the implant at
the buccal aspect compared with a lingual positioning.4–7 This may be explained by the higher
resorption of the buccal bone plates compared
with the lingual bone plates during healing after
tooth extraction so that a slope will be formed,
being higher at the lingual aspect compared with
the buccal aspect.8 This, in turn, means that the
closer the implant is to the lingual aspect and the
farther from the buccal aspect, the lesser the exposure of the implant body above the bony crest
will be.
Owing to anatomical, functional and esthetic
reasons, in a clinical situation, the axis of an implant placed into an extraction socket will be
more lingually located compared with the tooth
axis. This is explained by the presence of residual
defects between the implant body and the walls
of the extraction socket that will be larger and
more likely to occur at the buccal aspect compared with the lingual aspect.2 When an implant
is placed into an extraction socket, the recipient
site will generally be prepared with a lingual bodily displacement, maintaining more or less the
same axis of the alveolus. However, it has been
suggested that, owing to the different projection, if the axis of the implant is tilted in a lingual
direction, the implant will be located deeper
within the extraction socket than it would have
been had the same axis as that of the alveolus
been maintained,9 even though the margin will
be located at the same level as the buccal bone
crest.
The concept of implant positioning needs to
be further clariﬁed. Hence, the aim of the present
experiment is to evaluate the inﬂuence of implant positioning within an extraction socket on
the depth of the implant at the time of surgery
and on the buccal supracrestal exposure of the
implant surface after healing.

The research protocol was submitted to and approved by the ethics committee for animal research at the Universidade Estadual Paulista
(Araçatuba, Brazil). Eight Labrador dogs were included in the study. The animals had a mean
weight of approximately 30 kg and a mean age of
2 years and were housed in kennels on concrete
runs at the university’s ﬁeld laboratory with free
access to water and moistened balanced dog
food.
Clinical procedures

At each surgery, the animals were first preanesthetized with Acepran (0.05 mg/kg; UnivetVetnil, São Paulo, Brazil) and then anesthetized
with Zoletil (10 mg/kg; Virbac, São Paulo, Brazil)
and Xilazina (1 mg/kg; Cristália, São Paulo,
Brazil), supplemented with ketamine (¼ of the
dose of 10 mg/kg; Cristália, São Paulo, Brazil).
Before the surgical procedure, the pulp of the
mesial roots of the fourth mandibular premolars
was removed on both sides of the mandible, and
the root canals were ﬁlled with gutta-percha and
root canal cement (Mtwo, Endopocket, Epﬁll,
Sweden & Martina). The crowns were afterward
restored with composite (Adonis, Sweden &
Martina).
The surgical procedure began with an incision performed within the sulcus. The flaps
were elevated and the buccal and lingual alveolar bone plates were exposed. The fourth premolars were first hemisectioned and the distal
roots removed, together with the corresponding portion of the crowns. The distal alveoli
were subsequently prepared at the apex for implant placement. However, randomly, the drill
was tilted buccally at one site and lingually at
the other. Implants 11.5 mm in length and
3.5 mm in diameter (Alvim CM, Neodent, Curitiba, Brazil) and with a rough surface (sandblasted and acid etched) were placed with the
shoulder flush with the buccal bone (Figs. 1a &
b). At one site, the implant was placed in a buccal position (B-sites), in contact with the buccal
wall of the alveolus, while in the opposite jaw,
the implant was placed lingually (L-sites), in
contact with the lingual wall of the alveolus
(Figs. 2a & b).
Using a #15 UNC probe (Hu-Friedy,
Chicago, Ill., U.S.), the horizontal and vertical
dimensions of the remaining buccal or lingual

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Implant positioning within extraction sockets

Figs. 1a & b

Clinical buccal view. Implants
placed into the distal alveoli of
the fourth premolars in a
(a) lingual and (b) buccal
position. Note that the implant
in the lingual position was
deeper in relation to the lingual
bone crest compared with the
implant placed buccally.

Figs. 2a & b

Clinical occlusal view. Implants
placed into the distal alveoli of
the fourth premolars in a
(a) lingual and (b) buccal
position.

defects were measured, as well as the vertical
distance between the top of the bony crest and
the implant shoulder at the lingual aspect.
Abutments of appropriate length were attached to the implants and sutures were applied to allow nonsubmerged healing.
After completion of the surgery, the animals were given a vitamin compound (Potenay,
Fort Dodge Animal Health, Campinas, Brazil),
an anti-inflammatory and analgesic drug
(Banamine, Schering-Plough Animal Health,
Campinas, Brazil) and an antibiotic (Pentabiótico, Fort Dodge Animal Health, Campinas,

Brazil). Three times per week for the first two
weeks after surgery, the wounds were inspected for clinical signs of complications and
the implant abutments were cleaned and disinfected with chlorhexidine. Afterward, cleaning
was performed three times per week. The
animals were euthanatized four months after the
surgery, with overdoses of thiopental (Cristália,
Itapira, Brazil) and then perfused with a ﬁxative
(4% formaldehyde solution) through the carotid
arteries.

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Implant positioning within extraction sockets

camera (Nikon Digital DS-Fi2, Nikon), the following landmarks were identiﬁed (Fig. 3): the implant shoulder (IS), the top of the adjacent bony
crest (C), the most coronal point of contact between the bone and implant (B), the top of the
mucosal margin (PM), the surface of the implant
at the top of the threads (S), the outer contour of
the bony crest (OC) and the outer contour of the
periimplant mucosa (OM). The following measurements were performed using NIS-Elements
software (Version 4.1; Nikon, Tokyo, Japan) under
40× magniﬁcation: the vertical distance between IS and C, IS and B, as well as PM and IS.
PM–B was calculated from the data available.
Under 40× magnification, the width of the
alveolar bony crest was measured from S to OC
at the IS level (0 mm) and then apical to it at
each subsequent millimeter, up to 5 mm
(Fig. 3). The width of the periimplant mucosa
was measured at the IS level (0 mm) and then
up to 3 mm coronal to the abutment surface
and up to 3 mm apical to it, from S. Under 100×
magnification, the percentage of bone-to-implant contact (BIC%) was evaluated from the IS
to the apical extension of the implant, both
buccally and lingually.

Fig. 3

Data analysis

Histological preparation

Individual blocks containing the implant and the
surrounding hard and soft tissue were collected
from the mandible and ﬁxed in a 4% formaldehyde solution. The specimens were subsequently dehydrated in a series of graded ethanol
solutions and ﬁnally embedded in resin (LR
White, hard grade, London Resin, Reading, UK).
The blocks were cut along the buccolingual plane
using a diamond band saw ﬁtted in a precision
slicing machine (EXAKT 300, EXAKT Advanced
Technologies, Norderstedt, Germany) and then
reduced to a thickness of approximately 60 μm
using a cutting and grinding device (EXAKT 400,
EXAKT Advanced Technologies). The histological
slides were stained with Stevenel’s blue and
alizarin red and examined under a standard light
microscope for histometric analysis.

Mean values and standard deviations, as well as
the 25th, 50th (median) and 75th percentiles, were
calculated for each outcome variable. Differences between buccally (B-sites) and lingually
(L-sites) positioned implants were analyzed using the Wilcoxon signed-rank test for paired observations using IBM SPSS Statistics for Windows (Version 19.0; IBM Corp., Armonk, N.Y.,
U.S.). The vertical level of the bony crest and osseointegration (IS–C and IS–B) were the main
outcome variables. The level of signiﬁcance was
set at α = 0.05.

Results

In one animal, a fracture of the buccal wall of the
alveolus occurred during extraction and the animal
was excluded entirely from analysis. No artifacts
were generated during histological processing,
nor were any tissue blocks destroyed. Hence,
the B- and L-sites yielded n = 7. In the text,
Histological evaluation
mean values ± standard deviations are reported,
Under an Eclipse Ci microscope (Nikon, Tokyo, and in the tables, the medians and the 25th and 75th
Japan), connected to a computer through a video percentiles are included too.
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17

Fig. 3
Landmarks used for
histomorphometric analyses:
IS: implant shoulder;
C: top of the adjacent bony
crest; B: most coronal point of
contact between the bone
and implant; PM: top of the
mucosal margin; S (dashed
green line): the surface of the
implant at the top of the
threads; OC (dashed yellow
line): the outer contour of the
bony crest; OM (dashed blue
line): the outer contour of the
periimplant mucosa.

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Implant positioning within extraction sockets

Table 1

Table 1

Clinical dimensions (mm) of
the residual bone defects after
implant placement (n = 7).
Mean values (standard
deviations) and medians
(25th; 75th percentiles)
are reported.

Residual vertical depth

Residual horizontal gap

Buccal

Lingual

Buccal

Lingual

Buccal

Lingual

0.0

4.8 (1.3)

0.0

1.2 (0.4)

0.0

0.4 (0.3)

0.0

5.0 (4.3; 5.0)

0.0

1.0 (1.0; 1.3)

0.0

0.5* (0.3; 0.5)

4.3 (1.3)

0.0

1.2 (0.3)

0.0

0.0

1.5 (0.8)

5.0 (3.0; 5.0)

0.0

1.0 (1.0; 1.5)

0.0

0.0

1.0* (1.0; 1.8)

B-sites
L-sites

C–IS

C: top of the adjacent bony crest; IS: implant shoulder. No statistically signiﬁcant differences (p < 0.05) were found between the lingual defects at B-sites and the
buccal defects at L-sites for vertical depth and horizontal gap. *p < 0.05 between B-sites and L-sites for C–IS at buccal and lingual aspects.

Fig. 4
Ground sections illustrating
the histological healing after
four months at the B-sites
(20× magniﬁcation; Stevenel’s
blue and alizarin red stain).

Figs. 4 & 5

Fig. 5
Ground sections illustrating
the histological healing after
four months at the L-sites
(20× magniﬁcation; Stevenel’s
blue and alizarin red stain).

Table 2

IS–C

B-sites

IS–B

C–B
Residual vertical defect

S–C
Residual horizontal defect

Buccal

Lingual

Buccal

Lingual

Buccal

Lingual

Buccal

Lingual

Buccal

Lingual

1.6 (1.9)

0.1 (0.7)

1.6 (1.9)

0.6 (0.5)

1.9 (1.8)

1.7 (1.8)

0.3 (0.3)

1.6 (1.4)

0.2 (0.3)

1.2 (0.5)

*, **

L-sites

Absolute bone loss

0.7
(0.7; 1.4)

0.0
(-0.4;0.4)

0.7
(0.7; 1.4)

0.7
(0.3; 0.9)

1.5
(0.9; 1.7)

0.9
(0.9; 1.6)

0.1
(0.0; 0.4)

1.4
(0.7; 1.9)

0.1
(0.0; 0.5)

1.2*, **
(0.8; 1.5)

0.4 (0.7)

-0.8 (0.9)

0.4 (0.7)

0.7 (0.4)

1.4 (0.7)

1.0 (0.8)

1.1 (0.9)

1.6 (1.2)

0.4 (0.2)

0.5 (0.4)

1.2
(0.8; 2.5)

0.4
(0.3; 0.5)

0.3*
(0.3; 0.7)

*, **

0.5
(0.1; 0.8)

**

**

-0.6
(-1.2; -0.2)

*, **

*

0.5
(0.1; 0.8)

0.7
(0.5; 1.1)

1.6
(1.0; 1.8)

0.8
(0.4; 1.7)

*, **

*

1.2
(0.4; 1.7)

**

**

IS: implant shoulder; C: top of the adjacent bony crest; B: most coronal point of contact between the bone and implant; S: surface of the implant at the top of the threads.
*
p < 0.05 between B-sites and L-sites. **p < 0.05 between buccal and lingual aspects.

Table 3

BIC%

B-sites

L-sites

PM–C

PM–B

PM–IS

Buccal

Lingual

Total

Buccal

Lingual

Buccal

Lingual

Buccal

Lingual

31.2 (23.2)

34.9 (22.5)

33.1 (22.3)

3.9 (0.4)

2.8 (0.5)

4.2 (0.5)

4.4 (1.4)

2.3 (1.7)

2.7 (0.8)

13.4
(13.0; 52.6)

34.0
(16.6; 47.3)

23.9
(14.8; 49.9)

3.9*
(3.7; 4.2)

2.8*
(2.6; 3.1)

4.0
(3.9; 4.6)

3.8
(3.5; 4.7)

2.8**
(2.5; 3.3)

2.6
(2.3; 3.2)

35.2 (19.7)

31.6 (34.9)

35.0 (16.6)

4.2 (0.4)

2.5 (0.4)

5.1 (1.1)

4.3 (1.4)

3.8 (0.7)

3.3 (1.1)

30.7
(20.9; 47.7)

35.2
(25.6; 46.3)

33.0
(23.3; 47.0)

*

4.2
(4.1; 4.2)

*

2.5
(2.4, 2.8)

*

5.3
(4.3; 5.8)

PM: top of the mucosal margin; C: top of the adjacent bony crest; B: most coronal point of contact between the bone and implant; IS: implant shoulder.
*
p < 0.05 between buccal and lingual aspects. **p < 0.05 between B-sites and L-sites.

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*

3.7
(3.3; 5.4)

**

3.5
(3.3; 4.1)

2.9
(2.8; 3.5)

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Implant positioning within extraction sockets

Fig. 6

Fig. 7

C l i n i c a l e v a l u a t i o n (Table 1)

After implant placement, residual marginal bone
defects were observed that were 4.8 ± 1.3 mm
deep and 1.2 ± 0.4 mm wide at the lingual aspect of
the B-sites and 4.3 ± 1.3 mm deep and 1.2 ± 0.3 mm
wide at the buccal aspect of the L-sites. The distance between the lingual bone crest and the implant shoulder was 0.4 ± 0.3 mm at the B-sites and
1.5 ± 0.8 mm at the L-sites, the difference being
statistically signiﬁcant (p = 0.017). This indicates
that, despite the implant margin being placed ﬂush
with the buccal bone crest at both the B- and Lsites, the implant was approximately 1.1 mm
deeper with respect to the lingual bony crest when
positioned lingually within the extraction socket
compared with buccal positioning.
Histological evaluation

Ground sections showing examples of healing at
the B-sites are illustrated in Figure 4 and of healing
at the L-sites in Figure 5.

IS–B at the buccal aspect was 1.9 ± 1.8 mm at the
B-sites and 1.4 ± 0.7 mm at the L-sites. At the lingual aspect, it was 1.7 ± 1.8 mm and 1.0 ± 0.8 mm
at the B- and L-sites, respectively. None of the
differences were statistically signiﬁcant. At the
B-sites, after healing, marginal bone defects
were noted. The dimensions of the defects were
smaller at the buccal (0.3 mm high and 0.2 mm
wide) compared with the lingual (1.6 mm high
and 1.2mm wide) aspects. When the implants
were placed lingually (L-sites), vertical bone defects were found both at the buccal (1.1 ± 0.9 mm)
and at the lingual (1.6 ± 1.2 mm) aspects. It has to
be considered, however, that the coronal aspect
of the defect was included in the abutment region given that IS was located apical to C by approximately 0.8 mm. These defects were narrow
(≤ 0.5 mm). BIC% was similar at both sites, as
well as buccolingually, and ranged between
31.2% and 35.2% (Table 3).
The width of the buccal bone ridge (OC–S)
was larger at the L-sites compared with the Bsites. However, the difference was statistically
signiﬁcant only at the 1 mm level (Fig. 7).

H a r d - t i s s u e d i m e n s i o n s (Table 2; Fig. 6)
S o f t - t i s s u e d i m e n s i o n s (Table 3; Fig. 6)

IS–C at the buccal aspect was 1.6±1.9 mm at the
B-sites and 0.4 ± 0.7 mm at the L-sites. The
difference was statistically signiﬁcant. At the
lingual aspect, IS–C was 0.1± 0.7 mm and
-0.8±0.9mm at the B- and L-sites, respectively.
When the absolute instead of the relative values
were taken into account, the bone crest resorption at the lingual aspect was 0.6± 0.5 mm at the
B-sites and 0.7 ± 0.4 mm at the L-sites. None of
the differences between the B-sites and L-sites
for relative and absolute values at the lingual
aspect were statistically signiﬁcant.

PM–C and PM–B at the buccal aspect were
3.9 ± 0.4 mm and 4.2 ± 0.5 mm at the B-sites and
4.2 ± 0.4 mm and 5.1 ± 1.1 mm at the L-sites. None
of the differences were statistically signiﬁcant. The
periimplant mucosa was located more coronally at
the L-sites (3.8 ± 0.7 mm) compared with the
B-sites (2.3 ± 1.7 mm), the difference being statistically signiﬁcant. The width of the periimplant
mucosa was greater at the L-sites compared with
the B-sites. The differences were statistically signiﬁcant at all levels considered (Fig. 7).

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Table 2
Histological hard-tissue
dimensions (mm; n = 7). Mean
values (standard deviations)
and medians (25th; 75th
percentiles) are reported.
Table 3
Histological soft-tissue
dimensions (mm) and BIC%
(n = 7). Mean values (standard
deviation) and medians
(25th; 75th percentiles)
are reported.
Fig. 6
Graphic showing the mean
values of the dimensions of
the periimplant hard and soft
tissue. IS: implant shoulder;
C: top of the adjacent bony
crest; B: most coronal point
of contact between the bone
and implant; PM: top of the
mucosal margin.
Fig. 7
Graphic showing the mean
values of the alveolar softand hard-tissue width at the
buccal aspect after four
months of healing. The
continuous lines represent
the width of the tissue at the
L-sites, and the dotted lines
represent the width at the
B-sites. Red and blue lines
represent the mucosal and
bone widths, respectively.
IS: implant shoulder.

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Implant positioning within extraction sockets

Discussion
The ﬁrst aim of the present study was to evaluate
the inﬂuence of implant positioning within an extraction socket on the depth of the implant. The
apex of the alveolus was used as apical point for
preparation and the drills were tilted toward either
the buccal or the lingual aspects. No bodily displacements were applied. The implants were, consequently, placed in contact with the buccal or the
lingual walls of the extraction sockets. Clinically,
the lingual positioning of the implant is mainly
achieved by a bodily displacement. However, a
slight angulation of the implant may be applied toward the lingual bone wall when necessary for
anatomical or prosthetic reasons. In the present
experiment, the ﬁnal position was obtained by
changing the angulation in relation to the axis of
the extraction socket. The procedure applied in the
present experiment exaggerated the difference in
angulations of the implants between the two
groups, B- and L-sites, allowing the limits to be
tested. It was shown that placing the implant lingually resulted in the implant shoulder being
deeper with respect to the lingual bone crest compared with a buccal position, even though the implant margin was placed at the same level as the
buccal bone crest. This was due to the rotation of
the projection that occurred when the surgeon
placed the implant ﬂush with the buccal wall of the
extraction socket, as described previously in another experiment in dogs.9 From a clinical perspective, if a lingual tilting of the implant is included in
the procedure, a deeper positioning of the implant
can be expected compared with an implant placed
following the axis of the alveolus or in a buccal position. This should be taken into account if the buccal bone crest of the alveolus is used as the reference level to judge the depth of the recipient implant site.
In the present experiment, the placement of
an implant in a lingual position resulted in reduced supracrestal exposure of the implant
compared with a buccal positioning. This is in
complete agreement with other studies that
showed similar results.4–7 In an experiment in
dogs,4 implants placed immediately into extraction sockets were placed in the center of the alveoli at the control sites, and placed lingually and
0.8 mm deeper at the test sites. The supracrestal
exposure of the implants was higher at the centrally compared with the lingually positioned implants. In another experiment in dogs,6, 7 the implants were placed in a central position of the ex20 Volume 2 | Issue 1/2016

traction sockets of third premolars and lingually
in the alveoli of fourth premolars. After three
months of healing, higher supracrestal exposure
was found at the implants placed in the center of
the alveoli. These results were also validated by a
multivariate multilevel analysis on implants
placed into sockets immediately after tooth extraction.5 The reason for this outcome may be explained by the fact that the buccal wall of the extraction socket undergoes higher resorption
than the lingual wall does.8, 10 The healing at an
implant placed into an extraction socket immediately after tooth extraction will be affected by
this resorption. The more buccal the implant
placement, the greater the supracrestal exposure of the buccal surface of the implant will be.
This assumption has been further corroborated
by other experimental studies on implants
placed immediately into extraction sockets.11, 12
In these experiments in dogs, wide implants with
the same coronal dimensions as the extraction
sockets were placed on one side, and implants
narrower than the extraction sockets were used
on the other side. In the latter, a gap resulted between the buccal bone wall and the implant.
Higher buccal bone resorption was observed at
the wide compared with the narrow implants.
Factors such as the thickness of the buccal
bone and the size of the horizontal defects present at the time of implant placement may inﬂuence ridge alterations.13 It was shown that buccal bone crests of ≤1 mm and residual buccal
gaps of ≤ 1 mm presented higher vertical and horizontal resorption compared with buccal bone
crests of > 1 mm and residual buccal gaps of
> 1 mm.13 This may indicate that the distance between the outer contour of the bone crest at the
buccal aspect and the surface of the implant
plays the most important role. This, in turn,
means that the closer the implant is placed into
an extraction socket with respect to the outer
contour of the bone crest, the greater the
supracrestal exposure of the buccal surface of
the implant will be.
After four months of healing, the top of the
bone crest at the lingual aspect was located
0.1 mm below the implant shoulder at the B-sites
and 0.8 mm above the implant shoulder at the
L-sites. However, this does not mean that higher
resorption occurred at the lingual crest at the
B-sites compared with the L-sites. In fact, owing
to the different angulation of the implants with
respect to the axis of the alveolus, the implants at
the L-sites were located deeper with respect to

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Implant positioning within extraction sockets

the lingual bone crest at the time of placement
compared with the implants at the B-sites.
When the original position of the implants was
taken into account, similar absolute values of lingual bone crest resorption were found.
At the time of placement, defects were present opposite the implants. At the B-sites, lingual
defects with mean values of 1.6 mm in depth and
1.2 mm in width were still present after four
months of healing. At the L-sites, residual defects were also present at both the buccal
(1.1 mm) and the lingual (1.6 mm) aspects. At the
buccal aspect, the defects lay entirely between
the implant surface and the bone wall, while at
the lingual aspect, the residual defects were opposite the implant surface in the apical part and
opposite the abutment in the coronal part. In a
clinical situation, the implant is generally placed
in a lingual position and residual defects may be
present after healing. However, their presence
may not be detected clinically if they are very narrow (≤ 0.5 mm). BIC% was similar at the buccal
and lingual aspects, both at the B- and the
L-sites, demonstrating that the position of the
implants within the extraction sockets did not affect the degree of osseointegration. The lingual
position affected the height of the periimplant
mucosa, which was more coronal with respect to
the implant shoulder at the L-sites compared
with the B-sites.

Conclusion
In conclusion, at implants placed immediately into
extraction sockets, smaller buccal exposure above
the bone crest will occur when implants are placed
in a lingual compared with a buccal position. Moreover, implants placed lingually will be located
deeper within the extraction sockets compared
with those placed buccally when the implants are
tilted lingually or buccally, respectively, in relation
to the axis of the alveolus.

Acknowledgments
This study was supported by a grant from the
Ariminum Research and Dental Education Center,
Ariminum Odontologica (Rimini, Italy). The implants were provided by Neodent (Curitiba, Brazil).
The competent contributions of Mr. Sebastião
Bianco, Ribeirão Preto, Brazil, in the histological
processing are highly appreciated.

References
1.
Chrcanovic BR, Albrektsson T, Wennerberg
A. Dental implants inserted in fresh
extraction sockets versus healed sites:
a systematic review and meta-analysis.
→ J Dent.
2015 Jan;43(1):16–41.
2.
Botticelli D, Berglundh T, Lindhe J. Hardtissue alterations following immediate
implant placement in extraction sites.
→ J Clin Periodontol.
2004 Oct;31(10):820–8.
3.
Araújo MG, Sukekava F, Wennström JL,
Lindhe J. Ridge alterations following
implant placement in fresh extraction
sockets: an experimental study in the dog.
→ J Clin Periodontol.
2005 Jun;32(6):645–52.
4.
Caneva M, Salata LA, de Souza SS, Baffone
G, Lang NP, Botticelli D. Inﬂuence of
implant positioning in extraction sockets on
osseointegration: histomorphometric
analyses in dogs.
→ Clin Oral Implants Res.
2010 Jan;21(1):43–9.
5.
Tomasi C, Sanz M, Cecchinato D, Pjetursson
B, Ferrus J, Lang NP, Lindhe J. Bone
dimensional variations at implants placed in
fresh extraction sockets: a multilevel
multivariate analysis.
→ Clin Oral Implants Res.
2010 Jan;21(1):30–6.

10.
Pietrokovski J, Massler M. Alveolar ridge
resorption following tooth extraction.
→ J Prosthet Dent.
1967 Jan;17(1):21–7.
11.
Caneva M, Salata LA, de Souza SS, Bressan
E, Botticelli D, Lang NP. Hard tissue
formation adjacent to implants of various
size and conﬁguration immediately placed
into extraction sockets: an experimental
study in dogs.
→ Clin Oral Implants Res.
2010 Sep;21(9):885–90.
12.
Caneva M, Botticelli D, Rossi F, Cardoso LC,
Pantani F, Lang NP. Inﬂuence of implants
with different sizes and conﬁgurations
installed immediately into extraction
sockets on peri-implant hard and soft
tissues: an experimental study in dogs.
→ Clin Oral Implants Res.
2012 Apr;23(4):396–401.
13.
Ferrus J, Cecchinato D, Pjetursson EB, Lang
NP, Sanz M, Lindhe J. Factors inﬂuencing
ridge alterations following immediate
implant placement into extraction sockets.
→ Clin Oral Implants Res.
2010 Jan;21(1):22–9.

6.
Favero G, Lang NP, Favero G, León IG,
Salata LA, Botticelli D. Role of teeth
adjacent to implants installed immediately
into extraction sockets: an experimental
study in the dog.
→ Clin Oral Implants Res.
2012 Apr;23(4):402–8.
7.
Favero G, Botticelli D, Rea M, Pantani F,
León IG, Lang NP. Inﬂuence of presence or
absence of teeth adjacent to implants
installed immediately into extraction
sockets on peri-implant hard tissue levels:
an experimental study in the dog.
→ Clin Oral Implants Res.
2013 Mar;24(3):262–9.
8.
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.
9.
Favero G, Botticelli D, Favero G, García B,
Mainetti T, Lang NP. Alveolar bony crest
preservation at implants installed
immediately after tooth extraction:
an experimental study in the dog.
→ Clin Oral Implants Res.
2013 Jan;24(1):7–12.

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Flapless socket preservation procedure

Clinical and histological
evaluation of a flapless socket
preservation procedure:
A prospective single cohort study
Abstract
Objective
Valentina Borgia,* Fortunato Alfonsi,† Paolo Tonelli,†
Lorenzo Bertelli,† Saverio Marchionni,* Giovanna
Iezzi,§ Ugo Covani† & Antonio Barone*

The objective of this study was to evaluate the dimensional changes to hard
and soft tissue after a ﬂapless ridge preservation procedure in the posterior
area of the jaw.

Department of Surgical, Medical and Molecular
Pathology and Critical Care Medicine, University of
Pisa, Pisa, Italy
†
Department of Surgery and Translational Medicine,
University of Florence, Florence, Italy
§
Department of Medical and Oral Sciences and
Biotechnologies, “Gabriele d’Annunzio” University
of Chieti–Pescara, Chieti, Italy

Corresponding author:
Dr. Antonio Barone
Istituto Stomatologico Toscano
Versilia general hospital
Via Aurelia, 335
55043 Lido di Camaiore LU
Italy

Materials and methods

Patients requiring tooth extraction and subsequent implant restoration were
considered eligible for the study. Cortico-cancellous porcine bone and a resorbable collagen membrane were used to graft fresh extraction sockets, and
sutures were used to stabilize the membrane. Four months after the ridge
preservation procedure, all of the sites were re-entered, bone cores were harvested for histological and analysis, and implants were placed. The width of
keratinized gingiva, the thickness of the buccal bone wall, and the horizontal
and vertical bone dimensional variation were measured at baseline and after
four months.
Results

T +39 0584 6059888
F +39 0584 6058716
barosurg@gmail.com

How to cite this article:
Borgia V, Alfonsi F, Tonelli P, Bertelli L, Marchionni S,
Iezzi G, Covani U, Barone A. Clinical and histological
evaluation of a flapless socket preservation procedure: a prospective single cohort study.
J Oral Science Rehabilitation.
2016 Mar;2(1):22–30.

Thirty-seven patients were enrolled in the study. After four months, the
amount of vertical bone loss was 0.2 ± 0.7 mm for mesial sites,
1.1 ± 0.9 mm for buccal sites, 0.2 ± 0.8 mm for distal sites and 0.9 ± 0.9 mm
for palatal/lingual sites. The thickness of the buccal bone wall was found to
be correlated to the horizontal bone loss. The keratinized gingiva showed a
mean increase in the occlusal direction of 1.8 ± 0.7 mm. Newly formed bone
could be observed around the grafting material in the histological analysis,
even though residual grafted particles were still present.
Conclusion

In this study, we observed that the ﬂapless ridge preservation procedure
was effective in maintaining an adequate bone architecture, which allows
implant placement; moreover, this procedure improved the amount of keratinized tissue. The exposure of the resorbable collagen membrane to the
oral cavity did not jeopardize the healing process or the quality of the newly
formed bone.
Keywords

Ridge preservation, flapless, collagen membrane, post-extraction
socket, biomaterial.
22 Volume 2 | Issue 1/2016

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Flapless socket preservation procedure

Introduction
The treatment of extraction sockets is a daily
challenge in clinical practice. Several changes to
the bone dimensions occur after tooth extraction, since the alveolar bone is a tooth-dependent tissue.1 Bone modeling and remodeling are
unavoidable during healing of an extraction
socket.2–4 A number of studies have pointed out
that most of the resorption occurred during the
ﬁrst three months, although dimensional
changes have been observed up to one year after
a tooth extraction.5–7
The changes to the alveolar ridge after tooth
extraction showed the greatest amount of bone
loss in the horizontal dimension and a concomitant loss of vertical ridge height, which has been
reported to be more evident at the buccal level.5, 8, 9
The morphological changes at the extraction
sites resulted in narrow and short edentulous
alveolar ridges; moreover, the alveolar crest margin tended to shift lingually/palatally according
to a speciﬁc pattern. Some clinical data has indicated that the alveolar crest tends to move twothirds lingually/palatally from the original buccal
edge; thus, the amount of resorption at the midfacial point doubled the bone loss at the distal
and mesial points.8
A recent consensus report assessed that it is
important to distinguish between the various
procedures used to preserve the alveolar ridge.3
Ridge preservation techniques include all procedures that preserve the ridge volume within the
soft- and hard-tissue envelope existing at the
time of extraction.3 A ridge preservation procedure is recommended in the following circumstances: when implant placement is not possible
at the time of tooth extraction, when the patient
is not available for immediate implant placement, when primary stability of the implant cannot be guaranteed, and when treating adolescent patients.3 The use of various techniques and
biomaterials has been proposed over time; however, no signiﬁcant differences have been shown
between the various biomaterials, although collagen alone has been proved to be unable to
counteract tissue changes after tooth
extraction.5, 4, 10–12
An ideal grafting biomaterial should be resorbable, in order to allow replacement with new
bone while balancing the speed of resorption and
the volumetric stability. The use of a grafting material with a high resorption rate results in the
complete disappearance of the biomaterial after

a few months. This has been observed for calcium sulfate after three months and for a polylactide-polyglycolide acid sponge after six
months.13 Nevertheless, high resorption of the
biomaterial is not always desirable, especially in
anatomical sites where vertical and horizontal
volumetric shrinkage are expected. The use of
collagenated cortico-cancellous porcine bone
has shown positive results in socket preservation procedures after three months.14, 15 In fact,
histological and histomorphometric analyses
gave positive results in terms of newly formed
bone, absence of inﬂammatory cells and signs of
active resorption of the grafted particles,14 suggesting that collagenated cortico-cancellous
porcine bone could be suitable for ridge preservation procedures.
A full-thickness ﬂap elevation during tooth
extraction may have accounted for slightly more
pronounced bone remodeling compared with a
ﬂapless extraction, owing to the interruption of
the blood vessels.9, 16, 17 Soft-tissue primary closure was originally considered necessary for
proper incorporation of the graft.2, 9, 18, 19 The
early exposure of the membrane to the oral cavity
was thought to jeopardize the effectiveness of
tissue augmentation;16, 20 these ﬁndings pointed
out the importance of achieving full closure and
primary healing when the socket is grafted and
covered with a membrane.2
Experimental models have reported less pronounced bone remodeling when a ﬂapless approach was used for socket preservation,21 but
there is still no consensus on the effect of the elevation of a full-thickness ﬂap. However, one
study found no signiﬁcant difference between
the ﬂapless and ﬂapped approach.22 A recent
study observed the effects of a full-thickness
ﬂap elevation on the regenerative process of
socket preservation procedures.14 The comparison between the ﬂapped and the ﬂapless procedures showed no signiﬁcant differences in the
histological and histomorphometric analysis, in
terms of newly formed bone, residual graft and
marrow space rates, suggesting that the exposure of the collagen membrane did not jeopardize the regenerative process.14
The aim of the current study was to evaluate
the clinical outcomes of a ridge preservation
technique with a ﬂapless approach in the posterior area of the jaw. Dimensional changes to the
hard and soft tissue at fresh extraction sites
treated with the use of cortico-cancellous
porcine bone and a resorbable collagen mem-

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Flapless socket preservation procedure

brane were evaluated over the observation
period. Bone cores were also harvested at the
time of implant placement for histological
analysis.

Materials & methods
Study population and design

Patients were recruited from the consultation
clinic at the Istituto Stomatologico Toscano, Versilia general hospital, University of Pisa, Lido di
Camaiore, Italy, from January 2013 to January
2014. The study was approved by the ethics
committee of the Versilia general hospital according to the principles outlined in the Declaration of Helsinki on clinical research involving human subjects. All of the patients received a thorough explanation of the study and completed a
written informed consent form prior to being enrolled in the trial.
Forty patients requiring extraction of at least
one premolar or one molar and a subsequent implant-supported restoration who were 18 years
old or older and able to sign an informed consent
form were eligible for inclusion in this trial. One
patient showed complete loss of the buccal bone
plate immediately after the extraction and two
patients did not return for the follow-up examinations. Consequently, these patients were excluded, and 37 patients were included in the
study. The patients enrolled in the study had a
mean age of 40.5 ± 13.5 and an age range of between 20 and 61.

Patients who were included in the study were accurately evaluated by examining clinical aspects
and periapical and panoramic radiographs.
Moreover, data were collected for each patient,
including age, sex, smoking habits, and indications for tooth extraction based on both clinical
and radiographic examinations, tooth location
and the presence or absence of adjacent teeth.
After the consent form had been signed, all of
the patients underwent at least one session of
scaling and root planing prior to the extraction
procedures in order to provide a more favorable
oral environment for wound healing. All of the
patients underwent the tooth extraction and the
ridge preservation procedure at baseline. Four
months after tooth extraction, all of the sites
were re-entered, bone biopsies were taken and
implants were placed.
Surgical treatment

All of the patients received antibiotic therapy (2 g
amoxicillin or 600 mg clindamycin, if allergic to
penicillin) 1 h before the surgery and continued to
take the antibiotic postoperatively (1 g amoxicillin or 300 mg clindamycin) b.i.d. for four days.
All of the patients rinsed for 1 min with a 0.2%
chlorhexidine mouthwash prior to the surgery
(as well as b.i.d. for the following three weeks)
and were treated under local anesthesia using lidocaine with 1:50,000 epinephrine. All of the
surgical procedures were performed by two surgeons (AB, FA), who received training during a
one-week session before beginning the study.
The training included calibration for the surgical
and follow-up procedures, as well as the handling of any complications. All of the patients
The exclusion criteria were:
were treated with the same surgical technique
– history of systemic disease that would
and periotomes were used around every tooth
contraindicate oral surgical treatment
treated. Moreover, ultrasound bone surgery
– long-term nonsteroidal anti-inﬂammatory
(PIEZOSURGERY, mectron, Italy) was performed
drug therapy
– intravenous and oral bisphosphonate therapy where necessary in order to avoid buccolingual
movements of the tooth, thus preventing dam– lack of the occluding teeth
age to or a full fracture of the buccal bone wall.
– absence of adjacent teeth
The extraction sockets were thoroughly
– complete loss of a bone wall
curetted and irrigated with a sterile saline solu– surgical sites in the esthetic area
tion. Cortico-cancellous porcine bone (mp3, Os– uncontrolled periodontal disease
teoBiol, Tecnoss Dental, Pianezza, Italy) was
– unwillingness to return for the follow-up
lightly condensed inside the socket and a reexamination
– smoking of more than ten cigarettes per day— sorbable collagen membrane (Evolution, OsteoBiol, Tecnoss Dental) was placed over it in order
subjects who smoked fewer than ten cigarettes per day were requested to stop smoking to cover the socket completely. The membrane,
before and after surgery; however, their com- which was left exposed to the oral cavity, was
stabilized with 4-0 silk sutures, and soft-tissue
pliance could not be monitored.
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Flapless socket preservation procedure

Fig. 1

Figs. 1 & 2

Preoperative radiograph.
Tooth #25 was to be extracted
because of nontreatable root
decay.
Fig. 2
Example of the probe used for
the clinical measurements.
Fig. 3
Resin stent positioned on the
experimental site in order to
standardize the clinical
measurements.

Figs. 3 & 4

Fig. 4
Occlusal view of the
experimental site showing the
preoperative situation.
Fig. 5
Post-extraction socket.
Figs. 5 & 6

Fig. 6
Cortico-cancellous porcine
bone grafted inside the socket.
Fig. 7
Sutures used to stabilize the
graft and the collagen
membrane.
Fig. 8
Figs. 7 & 8

Occlusal view of the
experimental site four months
after the ridge preservation
procedure.

healing was by secondary intention, since no ﬂap
was raised (Figs. 1–8). All of the patients were instructed to continue the antibiotic therapy, and
550 mg naproxen sodium tablets were prescribed as an anti-inﬂammatory (b.i.d. as necessary). Removable prostheses, if present, were
not used for at least three weeks and then adjusted before reuse.

The surgical re-entry was performed four
months after the ﬁrst-stage surgery. Bone biopsies were collected and implants (BL CT, IntraLock, Boca Raton, Fla., U.S.) were placed (Fig. 9).
Of the implants placed, 61% had a diameter of
5 mm and 39% of 4 mm. Adjunctive augmentation procedures at the time of implant placement
were necessary in 7% of the experimental sites.

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Flapless socket preservation procedure

Fig. 9

Figs. 9 & 10

Implant placement.
Fig. 10
Implant uncovering.

Fig. 11

Figs. 11 & 12

Radiographs three months
after implant placement.
Fig. 12
Final prosthesis.

Three months after placement, the implants were – vertical bone changes, registered with a surgical stent positioned on the adjacent teeth and
uncovered and manually tested for stability
measured with a Williams periodontal probe
(Fig. 10). At this time, impressions were taken ussoon after the tooth extraction and at the time
ing a polyvinyl siloxane impression material (Flexof implant placement (four months after the
itime, Heraeus Kulzer, Hanau, Germany) and cusﬁrst-stage surgery)
tomized resin impression trays. Final ceramic
restorations were made and seated, and all of the – horizontal bone changes, measured with a
Williams periodontal probe soon after the
patients were enrolled in an oral hygiene program,
tooth extraction and after four months.
with a recall visit every three months (Figs. 11 & 12).
Clinical parameters

Histological analysis

Several clinical parameters were measured at
each time of examination, including at baseline
and four months after the ridge preservation
procedure. The clinical parameters taken into
consideration in the present study were

Bone biopsies were collected during the secondstage surgery. The bone cores were immediately
stored in a 10% buffered formalin solution and
sent to the Department of Medical and Oral Sciences and Biotechnologies, “Gabriele d’Annunzio” University of Chieti–Pescara, Chieti, Italy.
The samples were then processed to obtain thinground sections, using the Precise 1 Automated
System (Assing, Rome, Italy). The specimens
were dehydrated in a graded series of ethanol
rinses and embedded in a glycol methacrylate
resin (Technovit 7200 VLC, Heraeus Kulzer,
Wehrheim, Germany). After polymerization, the
specimens were sectioned along the longitudinal
axis with a high-precision diamond disc at approximately 150 μm and ground down to approximately 30 μm. Three slides were obtained from
each specimen, stained with acid fuchsin and

– width of keratinized gingiva, measured at the
midfacial point of the buccal aspect using a
Williams periodontal probe (at baseline, the
measure corresponded to the distance between the mucogingival junction and the gingival margin; at the four-month examination,
it was the distance between the mucogingival
junction and the highest part of the edentulous crest)
– thickness of the buccal bone, measured immediately after tooth extraction using a surgical caliper
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Table 1

Table 1

Age (years)

40.5 ± 13.5
(20 ←→ 61)

Males

15

Females

22

Experimental sites

37

Molars

25

Premolars

12

Mean buccal bone thickness at baseline (mm)

Demographic data.

2.1 ± 0.7
(1 ←→ 3)

Table 2

Table 2

Site

Baseline (mm)

4 months (mm)

Difference (mm)

P-value (baseline vs. 4 months)

Mesial

11.4 ± 1.1
(10 ←→ 14)

11.6 ± 1.3
(10 ←→ 15)

-0.2 ± 0.7
(-2 ←→ +1)

0.0367

Buccal

12.8 ± 1.2
(10 ←→ 15)

13.9 ± 1.1
(11 ←→ 16)

-1.1 ± 0.9
(-3 ←→ +1)

0.000000145
(1.45 × 10-7)

Distal

11.2 ± 1.1
(10 ←→ 15)

11.5 ± 1.1
(10 ←→ 14)

-0.2 ± 0.8
(-2 ←→ +1)

0.071

Lingual/
palatal

2.0 ± 1.4
(9 ←→ 14)

12.9 ± 1.4
(10 ←→ 15)

-0.9 ± 0.9
(-3 ←→ +1)

0.00000843
(8.43 × 10-6)

Horizontal bone
changes

9.2 ± 1.3
(7 ←→ 12)

7.6 ± 1.2
(5 ←→ 10)

-1.6 ± 0.5
(-3 ←→ -1)

< 0.0001
(4.5 × 10-20)

Width of keratinized
gingiva

2.8 ± 0.9
(1 ←→ 5)

4.6 ± 0.8
(3 ←→ 6)

1.8 ± 0.7
(1 ←→ 4)

< 0.0001
(5.7 × 10-17)

Clinical parameters

Vertical
bone changes

toluidine blue, and examined in transmitted and
polarized light using a transmitted light microscope (Leitz Laborlux, Leitz, Wetzlar, Germany).
One well-trained examiner (GI), who was not involved in the surgical treatment, evaluated the
histological results.
Statistical analysis

Descriptive statistical analysis was performed
on all of the data collected, with SPSS software
(Version 6.1.2; SPSS, Chicago, Ill., U.S.). Pearson’s
chi-squared test was performed for categorical
data. The p-value for signiﬁcance was set at
0.05. All of the measurements in the text and tables are given as medians and interquartile
ranges (the difference between the 75th and 25th
percentiles).

Results
A single-tooth extraction with a ﬂapless ridge
preservation procedure was performed for each
of the 37 patients enrolled in the study, with a
total of 25 molars and 12 premolars that needed

Dimensional changes four
months after the ridge
preservation procedure.

to be extracted owing to fracture (42%), nontreatable endodontic lesions (14%) and severe
root decay (44%). All of the surgical procedures
performed in this study were successful and no
complications were observed during the healing
period (Table 1).
At baseline, the mean width of keratinized
gingiva was 2.8 ± 0.9 mm (range of 1.0–5.0 mm).
After four months, it was 4.6 ± 0.8 mm, showing
an increase of 1.8 ± 0.7 mm, which was statistically signiﬁcant (p = 0.0001).
The thickness of the buccal bone was measured at baseline and ranged from 1.0 to 3.0 mm,
with a mean of 2.1 ± 0.7 mm (Table 1). The mean
width of the alveolar crest at baseline was
9.2 ± 1.3 mm, and after four months, it was
7.6 ± 1.2 mm; therefore, the mean width of the
alveolar crest showed a decrease of 1.6 ± 0.5 mm
(p < 0.0001). The comparison between the thickness of the buccal bone wall and the width of the
alveolar crest indicated that the correlation between the two values was statistically signiﬁcant (Table 2).
Four months after the ridge preservation procedure, the vertical bone loss was 0.2 ± 0.7 mm
for mesial sites, 1.1 ± 0.9 mm for buccal sites,

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Fig. 13
Newly formed bone around
the grafting material. No
inﬂammatory cells or foreign
body reaction was observed.

0.2 ± 0.8 mm for distal sites and 0.9 ± 0.9 mm for
palatal/lingual sites. The dimensional changes
were statistically signiﬁcant for all of the sites
(Table 2).
The histological analysis performed on the
retrieved bone cores found that the granules of
grafted bone were still present, even though new
trabecular bone could be observed in all of the
specimens. Osteocytic lacunae could be seen on
the particles’ surfaces, and newly formed bone
was observed inside some of the resorption areas of the biomaterial. Vascular growth close to
the newly formed bone was also evident, and no
inﬂammatory cells or foreign body reaction
around the biomaterial granules was observed
(Fig. 13).

Discussion
Ridge preservation techniques have been proposed in order to reduce the bone volume shrinkage that follows a tooth extraction, since several
studies have reported resorption of both vertical
and horizontal dimensions.1, 6, 7, 23 The use of various biomaterials and techniques has been proposed over time, but there is still no evidence to
indicate the best choice. In the present study, 37
single-tooth extractions and the subsequent
ﬂapless ridge preservation procedures were performed. Cortico-cancellous porcine bone and a
resorbable collagen membrane were used in all
of the cases, and several clinical parameters
28 Volume 2 | Issue 1/2016

were measured at the tooth extraction and after
four months, including width of keratinized gingiva, thickness of the buccal bone wall, and
changes to the vertical and horizontal dimensions.
A minimally invasive tooth extraction technique, with preservation of the socket walls during the surgery, helps to maintain the architecture of the alveolar crest,1, 4 even if bone remodeling is not completely avoidable.9 A ﬂapless
surgical technique was chosen in our study because, even though some studies have not reported any signiﬁcant differences between a
ﬂapped and a ﬂapless surgical technique,5, 24 Van
der Weijden et al. assert that the elevation of a
full-thickness ﬂap is believed to compromise the
blood supply, limiting the future regenerative potential.23 Furthermore, the use of a ﬂapless technique has been demonstrated to be less traumatic for both hard tissue—avoiding interruption
of the blood ﬂow—and soft tissue—preserving
the keratinized gingiva.25, 15, 26 The exposure of
the collagen membrane and the soft-tissue closure by secondary intention seemed not to jeopardize the bone healing, and 100% of the ridge
preservation procedures were successful. The
width of the keratinized gingiva gained
1.8 ± 0.7 mm after four months. These results
correspond to those of other studies that used a
similar surgical protocol.14
The evaluation of the clinical parameters in
this study conﬁrmed the efﬁcacy of this surgical
procedure in counteracting the soft- and hard-

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tissue shrinkage after a tooth extraction: both
the vertical and horizontal dimensions showed a
minimal decrease. In particular, the vertical dimension lost 0.2 ± 0.7 mm at the mesial sites,
1.1 ± 0.9 mm at the buccal sites, 0.2 ± 0.8 mm at
the distal sites and 0.9± 0.9mm at the
palatal/lingual sites after four months. These results are in keeping with those reported in a recent systematic review that compared the outcomes after tooth extractions with and without
ridge preservation procedures.27 In the case of
the ridge preservation procedures, the vertical
bone changes ranged from a gain of 1.3 ± 2.0 mm
to a loss of 0.62 ± 0.51 mm, with follow-up times
ranging from three to nine months.27
In the current study, the ridge preservation
procedures in all of the experimental sites were
successful, and implants were placed after four
months, with further augmentation procedures
being necessary only in 7% of the cases at the
time of implant placement. Moreover, bone
cores were harvested for the histological analysis at the time of implant placement. Corroborating the ﬁndings of other studies,28, 29 this study
found that the cortico-cancellous porcine bone
was effective in maintaining the architecture of
post-extraction sockets and demonstrated signs
of active resorption at the same time. Iezzi et al.
examined the use of various biomaterials and
performed histological and histomorphometric
analyses after six months.28 Among the different
grafting materials, cortico-cancellous porcine
bone gave rise to a rim of osteoblasts with signs
of active bone matrix deposition; in some areas,
bone apposition was observed directly on the
particles’ surfaces.28 Similarly, the biomaterial
used in this study showed a great percentage of
newly formed bone. No inﬂammatory cells or
foreign body reaction was observed in the bone
samples, but new bone tissue and blood vessel
growth. Active resorption signs were evident,
since osteocytic lacunae were observed at the
surface of the biomaterial granules. As found by
another study,29 collagenated porcine bone was
demonstrated to be resorbable, showing active
resorption signs on the surface of the particles.
Another study investigated the effect of the
exposure of the resorbable membrane to the oral
cavity on bone healing, comparing a ﬂapped and
a ﬂapless approach.14 The percentages of newly
formed bone, residual graft particles and marrow spaces were similar for the two groups, suggesting that the exposure of the collagen membrane had no detrimental effect on the regenera-

tive process.14 Similarly, in our study, the secondary intention healing seemed not to affect the
bone quality, as seen in the bone cores. The ﬁndings of this study support the hypothesis that
secondary intention healing and exposure of the
collagen membrane do not jeopardize bone regeneration, but improve the amount of keratinized gingiva. The ridge preservation technique
was demonstrated to be effective in maintaining
an adequate bone architecture, allowing the
subsequent implant placement without adjunctive augmentation procedures in the majority of
the cases
Further studies are necessary to evaluate the
inﬂuence of early exposure of the membrane on
the formation of new bone and on the integration
of the grafting material over time. Furthermore, a
longer follow-up period could be useful in order
to monitor the success of the biomaterial and the
quality of the newly formed bone.

Conclusion
Within the limits of this prospective cohort study,
ridge preservation showed adequate regeneration
of the bone and stability of the facial soft-tissue
level. The ﬂapless ridge preservation procedure
maintained the horizontal and vertical bone dimensions, improving the amount of keratinized
tissue. The exposure of the resorbable collagen
membrane to the oral cavity seemed not to jeopardize the healing process or the quality of the
newly formed bone.

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

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Vittorini Orgeas G, Clementini M, De Risi V,
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Novaes AB Jr, Martins de Barros RR,
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Review of the arterial anatomy in the anterior mandible

Review of the arterial vascular
anatomy for implant placement
in the anterior mandible

Abstract
Objective
José Carlos Balaguer Marti,* Juan Guarinos,†
Pedro Serrano Sánchez,† Amparo Ruiz Torner,*
David Peñarrocha Oltra* & Miguel Peñarrocha Diago*
*

Department of Stomatology, Faculty of Medicine and
Odontology, University of Valencia, Valencia, Spain
†
Department of Anatomy, Faculty of Medicine and
Odontology, University of Valencia, Valencia, Spain

The placement of implants in the anterior region of the mandible is not
free of risk and can even sometimes be life-threatening. The aim of this
article is to review the anatomy of the anterior mandible regarding the
placement of implants in this region.
Materials and methods

An anatomical study was conducted in cadavers to analyze the various
anatomical structures of the anterior region of the mandible. A literature
review was also undertaken.

Corresponding author:
Dr. David Peñarrocha Oltra
Clínicas odontológicas
Gascó Oliag, 1
46021 Valencia
Spain

Results

The sublingual and submental arteries are the main supply of the sublingual region. These arteries are usually located at a safe distance from the
alveolar ridge, but in cases of severe atrophy or anatomical variations,
there may be an increased risk of damage during the placement of dental
implants and serious complications may arise.

T & F +34 963 86 4139
david.penarrocha@uv.es

How to cite this article:
Balaguer Marti JC, Guarinos J, Serrano Sánchez P,
Ruiz Torner A, Peñarrocha Oltra D, Peñarrocha Diago M.
Review of the arterial vascular anatomy for implant
placement in the anterior mandible.
J Oral Science Rehabilitation.
2016 Mar;2(1):32–9.

Conclusion

The injury of the vessels in the floor of the mouth could lead to severe
complications. Implant surgery in the anterior mandible should be
planned with 3-D radiographic imaging to establish accurate 3-D positioning of the implant.

Keywords

Anatomy, arteries, mandible, hemorrhage, dental implants.
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Review of the arterial anatomy in the anterior mandible

Introduction
Knowledge of the topographic anatomy of the
mandibular region is very important in implant
dentistry. Severe, life-threatening complications can occur after dental implant placement
in the mandible, especially in the anterior region. In the case of arterial vascular trauma in
the floor of the mouth during implant placement in the mandibular anterior region, surgeons should be prepared to manage a severely
compromised oropharyngeal airway.1
The number of complications associated
with implantology has risen owing to the increasing number of implants being placed. An
electronic search performed in the MEDLINE
(PubMed) and Embase databases with the
search term “dental implants” indicated that the
number of articles related to dental implants increases every year. Worthington wrote, “The
number of practitioners performing implant
surgery has increased dramatically over the last
fifteen years. As confidence is gained, they tend
to accept increasingly challenging cases and it
is to be expected that the incidence of problems
and complications will increase. Serious problems and complications may result from inadequate treatment planning, some from careless
instrumentation, and some from lack of appropriate precautions.”2 Some important early
complications after dental implantation may be
neurological,3, 4 infections5 and hemorrhages,6, 1, 7
Neurological complications are the most frequent (8.5%),4 followed by infections (1.8%),8
and severe, life-threatening hemorrhagic complications are the most rare, with only 15 cases
reported in the literature.6
Although severe immediate hemorrhagic
complications are infrequent, the mechanical
pressure from sealed bleeding spaces adjacent
to the upper airway may become life-threatening extremely quickly.1 Therefore, these are the
most serious complications, especially when
they occur in the anterior region of the
mandible. Laceration of the inferior alveolar artery can lead to severe bleeding, but the compression by the implant itself can stop the hemorrhage. The floor of the mouth is not a closed
cavity like the canal of the inferior alveolar
nerve; therefore, if bleeding occurs, the blood
collects in the supramylohyoid space, pressing
the tongue to the palate. Thus, perforation of
the lingual cortical plate in the anterior region
of the mandible can cause uncontrollable

bleeding of the sublingual artery, which requires in-hospital treatment.6 The practitioner
must have an extensive knowledge of the
anatomy of the surgical field to avoid this complication.
This paper highlights the essential anatomical details that must form part of the practitioner’s knowledge in order to perform dental
implant surgery in the anterior mandible with
maximum safety and minimal risk.

Materials & methods
A study of the anatomical body structures located in the anterior mandible and ﬂoor of mouth
was performed. The cadavers used were donated by the University of Valencia (Valencia,
Spain). An intravascular perfusion with colored
latex was performed for better discrimination of
the vessels. The tissue was dissected with the
blunt technique principally—closed scissors
were inserted into the connective tissue and then
opened. The structures were recorded photographically.
A literature review was conducted to assess
the anatomy of the anterior mandible, through a
search in electronic databases, namely MEDLINE (PubMed), Embase and the Cochrane Library. Boolean operators and truncation were
used for the search. The search terms used were
“(anatomy OR vessel* OR muscle OR artery) AND
anterior AND mandible.” The inclusion criteria
were case reports, anatomical studies on cadavers or radiographic studies of the anatomy of the
ﬂoor of the mouth and the anterior mandible,
performed in humans. The exclusion criterion
was anticoagulated patients.

Results
Bony anatomy and musculature
of the sublingual region

Among the soft tissues surrounding the mandible are the ﬂoor of the mouth (made of up the
sublingual region and the tongue itself), and the
mental and genial areas. The sublingual region is
limited below by the mylohyoid muscle, laterally
by the hyoglossus, genioglossus and geniohyoid
muscles, above by the mucosa of the ﬂoor of the
mouth, and anteriorly by the body of the mandible (Fig. 1).

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Review of the arterial anatomy in the anterior mandible

Fig. 1

Anatomical structures
of the sublingual space.
Coronal plane.

Fig. 2

mental spine (Figs. 1 & 2). The digastric fossa,
from which the anterior digastric muscle originates, is located on the mandible’s inner side,
near the lower edge in the paramedian location
(Fig. 3).
Sublingual artery

The sublingual artery follows a medial course to
the mandible within the sublingual gland and
supplies the mylohyoid muscle (Fig. 4). It is at the
level of this muscle that the sublingual artery issues branches that anastomose with the submental artery.11 The artery ends in the mental
spine.
Submental artery
Fig. 2
Anatomical structures
of the sublingual space.
Sagittal plane.

The mandible in the symphyseal area is dropshaped and tilted toward the lingual area. The
mandibular symphysis is the medial area of the
mandible that results from the endochondral ossiﬁcation and the subsequent mergence of
Meckel’s cartilage in the 24th week of intrauterine life.9 At that time, the musculature forms,
affecting the development and subsequent
growth of the mandible.10 In this region, the mental spines stand out where the quadratus labii inferioris muscle forms. The superior and inferior
mental spines are located on the mandible’s inner side (Fig. 2). The genioglossus muscle originates from the superior mental spine, while the
geniohyoid muscle originates from the inferior
34 Volume 2 | Issue 1/2016

This artery is a branch of the facial artery. It
passes together with the mylohyoid nerve along
the inferior surface of the homonymous muscle
to the anterior region, where it supplies the anterior digastric muscle (Fig. 5). At this anterior
level, the perforating branches of the submental
artery pierce the mylohyoid muscle to anastomose with perforating branches of the sublingual artery.12
Va s c u l a r a n a s t o m o s i s

There are many anastomoses of the arteries involved in the sublingual region. An anastomosis
found between the lingual and the submental ar-

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Review of the arterial anatomy in the anterior mandible

Figs. 3 & 4

Figs. 5 & 6

teries runs along the bottom ﬂange of the
mandibular body and through the mylohyoid
muscle (Fig. 6). Anastomoses between both
sublingual contralateral arteries in the symphysis are frequent too (Fig. 7).
In summary, the mandibular symphyseal area
is supplied by multiple vascular structures from
different origins and presents a variability dependent on the anastomosing relationships established
by the terminal branches of these structures.13–15

Discussion
The sublingual region is well vascularized, with
several anastomoses that can impair hemostasis
if bleeding occurs.7 Treatment can be uncomfortable for the patient, so the priority is to prevent trauma occurring through good anatomical
knowledge of the area and proper planning of the
surgery.
Regarding the bony anatomy and musculature of the anterior mandible, the mental spines
are located in the mandible’s inner side. Some

studies highlight its morphological variability, for
example the variability in the distance from the
mental spine to the inferior border of the
mandible or to apices of the mandibular incisors.16 The genioglossus and geniohyoid muscles originate from the mental spines, so this
variability may increase the risk of damage to
these structures when dental implants are
placed in this area.
The digastric fossa is located on the
mandible’s inner side, near the lower edge in the
paramedian location. Therefore, an injury caused
by piercing of the mandibular cortical bone, for
example when placing a dental implant, may affect different muscles depending on whether the
implant preparation is in the medial or paramedian location in relation to the mandibular symphysis.17
Three arteries supply this anatomical region:
(a) the sublingual artery, which is a branch of the
lingual artery; (b) the submental artery, which is
a branch of the facial artery; and (c) the chin artery, which is the terminal branch of the inferior
alveolar artery. The lingual and facial arteries are

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Fig. 3
Musculature of the mandible
and sublingual artery piercing
the mandibular lingual plate.
Fig. 4
Anatomical photograph of the
arterial supply of the ﬂoor of
the mouth.
Fig. 5
Course of the facial and
submental arteries.
Fig. 6
Location of the sublingual and
submental arteries. (Modiﬁed
from Kalpidis and Setayesh1
with permission from the
American Academy of
Periodontology.)

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Review of the arterial anatomy in the anterior mandible

Fig. 7

Anastomosis of the sublingual
arteries.
Fig. 8
Mandibular medial lingual
canal.

Fig. 8

both branches of the external carotid artery
and the inferior alveolar artery is a branch of the
maxillary artery.11
Katsumi et al. classify the arterial supply to
the floor of the mouth into four types.18 In Type
I, the sublingual region is supplied by the sublingual artery. In Type II, it is supplied by the
sublingual and submental arteries. In Types III
and IV, it is supplied by the submental artery
(the difference between the last two being that
in Type III the deep lingual artery—which supplies the tongue—originates from the lingual
36 Volume 2 | Issue 1/2016

artery, and in Type IV it comes from the submental artery).
The sublingual artery is the main supply of
the sublingual region. Anatomical and radiographic studies have identified lingual vascular canals in the mandible where the sublingual
artery pierces the mandibular lingual cortical
plate (Figs. 6 & 8).19–21 The frequency of lateral
lingual canals in the area of the mandibular incisors varied between 33.1% and 100.0% and
in the area of the canines between 69.0% and
80.0% of the cases.19–21 The location of the lingual canals coincided with the most frequent
sites of clinically important bleeding during implant placement. The diameter of the canals
was on average 1.2 mm, which is enough to produce severe sublingual bleeding.22 Katakami et
al. observed anastomoses between the lateral
lingual canals and the inferior alveolar canal in
20.1% of the cases.6, 21
The inferior alveolar artery provides an intraosseous blood supply to the symphyseal
area and the mandibular incisors by an incisal
branch that runs through the incisal canal. This
canal has an average length of 19.78 mm from
the mental foramen toward the midline.13 The
mental artery branches from the inferior alveolar artery inside the mandibular canal and exits
the mandible through the mental foramen. It
supplies the chin and anastomoses with its

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Figs. 9 & 10

counterpart on the opposite side and the submental and inferior labial arteries.12
There are several anastomoses between the
major arteries supplying the ﬂoor of the mouth
and the sublingual region. This fact is important
because bleeding is more difﬁcult to control
whenever anastomoses are present. The following anastomoses have been documented in the
literature: between the facial and the lingual arteries,1, 18 between the inferior alveolar artery
and the submental artery, and between the inferior alveolar artery and the sublingual artery
through the lingual cortical plate,15 and in close
relationship with the lingual cortical plate in 54%
of the cases.14, 22
Recommendations for placement
of implants in mandibular areas

The sites with the highest risk of clinically important bleeding are the symphysis and the canine
region—these coincide with the locations of the
lingual canals, a fact that might help explain this
bleeding.6, 1 Moreover, the concavity in the symphysis may lead to perforation of the vestibular
cortical plate if the implant is placed axially in the
symphysis, whereas if an implant is placed tilted
in the buccolingual direction, with the implant
apex toward the lingual cortical plate, it can perforate the lingual cortical plate (Figs. 9a–c). For
this reason, implants should be placed slightly
tilted toward the vestibular cortical plate, as
shown in Figure 9c. The shape of the mandible in
the posterior region is as shown in Figure 10,
with a depression in the lingual cortical plate
under the mylohyoid line. The depth of this
submandibular fossa is greater than 2 mm
(Figs. 10a & b) in 71.5–80.0% of patients.23, 24

The presence of this fossa increases the risk of
perforating the lingual cortical plate and of injuring the terminal branches of the sublingual artery
during implant placement. However, in the posterior mandible, this risk is lower because the
sublingual artery passes further from the lingual
cortical plate.25 To our knowledge, only two
cases of perforation of the lingual cortical plate in
the posterior mandible have been reported in the
literature.26
Tilting of implants in the posterior mandible
is again a possible solution in order to avoid the
submandibular fossa and maximize the use of
the bone available in patients with bone atrophy
in this region. Because the inferior alveolar nerve
is closer to the mandibular lingual cortical bone27
and the alveolar crest height over the submandibular fossa may be limited, a novel approach has been proposed using implants tilted
in a buccolingual direction, tipping the implant
apex toward the vestibule (Fig. 10).28
Conventionally, longer implants have been
used in the anterior mandible than in other regions of the mandible or in the maxilla, owing to
the lack of important anatomical structures such
as the maxillary sinus or the inferior alveolar
canal. Several authors have reported the appearance of sublingual hematomas after placement
of dental implants of ≥ 15 mm in length in the anterior region of the mandible.6, 1 This is the median distance from the sublingual artery to the
top of the alveolar ridge.25 The use of shorter
dental implants may be advisable in the anterior
region to reduce the risk of severe bleeding complications.
The use of 3-D imaging techniques and
planning software may be useful to reduce the
risk of bleeding complications. Correa et al.

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Figs. 9 a–c
Correct angulation of the
implant (c) to avoid perforation
of the vestibular (a) or lingual
(b) cortical plate in the anterior
region of the mandible.
B: buccal aspect; L: lingual
aspect.
Figs. 10 a & b
Implant tilted (b) to avoid
perforation of the lingual
cortical plate (a) in the
posterior region of the
mandible when a deep
submandibular fossa is
present. L: lingual aspect;
B: buccal aspect.

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found that narrower and shorter implants
tended to be selected when the available bone
was studied using CBCT cross-sectional images, compared with both digital panoramic
radiographs and CBCT-generated panoramic
views.29 Moreover, guided implant surgery
may potentially enhance safety even further by
avoiding vessels, nerves and other anatomical
structures if the case is planned properly. However, at present, this cannot be definitively
stated yet. In a recent review on guided surgery, Tahmaseb et al. found a mean deviation of
up to 7.1 mm.30 It is necessary to control the factors that significantly affect the accuracy of
guided surgery, such as the experience of the
operator,31 the software used,32, 33 the type of
support for the guided template (soft tissue,
bone or dental support), the type of surgery
(flap vs. flapless) and the guided surgery system used.30
The anterior region of the mandible has a
high bone density, Type I according to the
Lekholm and Zarb classification.34 This property helps to achieve adequate primary stability, which, together with the absence of
anatomical limitations, such as the inferior
alveolar nerve and reduced atrophy, has conventionally led students to place their first implants in this area. The risks of placement of
dental implants in the anterior region of the
mandible highlight that the conventional recommendation to students to place their first
implants in the anterior region of the mandible,
owing to the absence of important anatomical
structures, should be reviewed.

38 Volume 2 | Issue 1/2016

Conclusion
The sublingual region is densely supplied by
several arteries that often anastomose. Injuring these vessels can cause serious bleeding
and even threaten the patient’s life through the
blocking of the upper airway. In order to avoid
these complications, the operator should have
an extensive anatomical knowledge of this
area. Moreover, tilting of implants, the avoidance of long dental implants, and careful surgical planning with the aid of 3-D imaging and
planning software may also help to reduce the
risks when placing implants in the anterior
mandible.

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

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Troupis TG, Dimitroulis D, Paraschos A,
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Katsumi Y, Tanaka R, Hayashi T, Koga T,
Takagi R, Ohshima H. Variation in arterial
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Kilic E, Doganay S, Ulu M, Çelebi N,
Yikilmaz A, Alkan A. Determination of
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region before implant surgery to prevent
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Tagaya A, Matsuda Y, Nakajima K, Seki K,
Okano T. Assessment of the blood supply to
the lingual surface of the mandible for
reduction of bleeding during implant
surgery.
→ Clin Oral Implants Res.
2009 Apr;20(4):351–5.

21.
Katakami K, Mishima A, Kuribayashi A,
Shimoda S, Hamada Y, Kobayashi K.
Anatomical characteristics of the
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limited cone-beam CT images.
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31.
Cushen SE, Turkyilmaz I. Impact of operator
experience on the accuracy of implant
placement with stereolithographic surgical
templates: an in vitro study.
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22.
Loukas M, Kinsella CR, Kapos T, Tubbs RS,
Ramachandra S. Anatomical variation in
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32.
Behneke A, Burwinkel M, Knierim K,
Behneke N. Accuracy assessment of cone
beam computed tomography-derived
laboratory-based surgical templates on
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23.
Parnia F, Fard EM, Mahboub F, Hafezeqoran
A, Gavgani FE. Tomographic volume
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patients requiring dental implants.
→ Oral Surg Oral Med Oral Pathol
Oral Radiol Endod.
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24.
Yildiz S, Bayar GR, Guvenc I, Kocabiyik N,
Cömert A, Yazar F. Tomographic evaluation
on bone morphology in posterior
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33.
Vasak C, Strbac GD, Huber CD, Lettner S,
Gahleitner A, Zechner W. Evaluation of
three different validation procedures
regarding the accuracy of template-guided
implant placement: an in vitro study.
→ Clin Implant Dent Relat Res.
2015 Feb;17(1):142–9. Epub 2013 May 16.
34.
Lekholm U, Zarb G. Patient selection and
preparation.
→ In: Brånemark P-I, Zarb GA, Albrektsson
T, editors. Tissue-integrated prostheses:
Osseointegration in clinical dentistry.
Chicago: Quintessence Publishing;
1985. p. 199–209.

25.
Mardinger O, Manor Y, Mijiritsky E,
Hirshberg A. Lingual perimandibular
vessels associated with life-threatening
bleeding: an anatomic study.
→ Int J Oral Maxillofac Surg.
2007 Jan-Feb;22(1):127–31.
26.
Bidra AS. Management of pain and
sublingual hematoma caused by suture
irritation after implant surgery: a clinical
report.
→ J Prosthet Dent.
2015 May;113(5):360–5.
27.
Gowgiel JM. The position and course
of the mandibular canal.
→ J Oral Implantol.
1992;18(4):383–5.
28.
Peñarrocha Diago M, Maestre Ferrín L,
Peñarrocha Oltra D, Canullo L, Calvo
Guirado JL, Peñarrocha Diago M. Tilted
implants for the restoration of posterior
mandibles with horizontal atrophy:
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29.
Correa LR, Spin-Neto R, Stavropoulos A,
Schropp L, da Silveira HED, Wenzel A.
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→ Clin Oral Implants Res.
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30.
Tahmaseb A, Wismeijer D, Coucke W,
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Tr a n s c r e s t a l s i n u s f l o o r e l e v a t i o n w i t h a s o n i c i n s t r u m e n t

Transcrestal sinus floor elevation
performed twice with
collagen sponges and using
a sonic instrument

Abstract
Objective
Ivo Agabiti* & Daniele Botticelli†
*

Private practice, Pesaro, Italy
Ariminum Research and Dental Education Center,
Ariminum Odontologica, Rimini, Italy; Programa
Odontológico Internacional, Cartagena de Indias,
Colombia

†

The objective of this study was to describe a minimally invasive transcrestal modiﬁed technique for sinus ﬂoor elevation performed twice
with a sonic instrument (Sonosurgery).
Materials and methods

During the ﬁrst surgical stage, a split-thickness ﬂap was dissected and an
osteotomy performed to prepare a crestal bone window using a sonic surgical device. The bone window was subsequently pushed apically toward
the sinus and only collagen sponges were compressed into the subantral
created space. After four months of healing, a second surgical stage followed using similar procedures to those used in the ﬁrst stage, and implants were subsequently placed.

Corresponding author:
Dr. Ivo Agabiti
Viale Napoli, 34
61121 Pesaro PU
Italy
T +39 0721 400056
ivoagabiti@sonosurgery.it

Results

How to cite this article:
Agabiti I, Botticelli D. Transcrestal sinus floor
elevation performed twice with collagen sponges
and using a sonic instrument.
J Oral Science Rehabilitation.
2016 Mar;2(1):40–7.

After three years, from the analyses of the cone beam computed tomography scans, no marginal loss was found and bone was observed all
around the implant surface. No complaints were reported by the patient. At the clinical follow-ups, no clinical signs of periimplant softtissue inﬂammation and no technical complications were noted during
the three-year period of observation.
Conclusion

The technique illustrated in the present article allowed the placement of
implants of proper length in a widely pneumatized sinus where the bone
height of the ﬂoor was insufficient for immediate stabilization. After
three years of function, neither marginal bone loss nor clinical signs of
inﬂammation were observed.
Keywords

Sonosurgery, sonic instrument, sinus floor elevation, transcrestal
approach, collagen sponge, sinus lift.
40 Volume 2 | Issue 1/2016

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Introduction
After tooth extraction, shrinkage of the alveolar
process is expected that may reach 50% of the
original horizontal width.1 In the posterior maxilla, the resorption of the radicular portion of the
sockets that may protrude into the sinus could
yield a further bone volume reduction due to
sinus pneumatization. In the molar area, the resorption is greater than in the premolar area, owing to the larger volume of the extraction sockets
that requires more time to be ﬁlled by newly
formed bone, thus allowing the time for sinus
pneumatization.2
In periodontally compromised patients, a
large sinus pneumatization, together with the
concomitant alveolar crestal resorption, may result in an inadequate bone height, which may
hinder the primary stability of implants in the
edentulous posterior maxilla.3–5
The maxillary sinus ﬂoor elevation technique
with a lateral approach has been well described
in literature.6 This surgical approach was based
on a previously unpublished technique presented by Tatum at the Alabama Birmingham
meeting in 1976. The safety and reliability of the
technique have received large consensus by clinicians and researchers. Several modiﬁcations of
the sinus ﬂoor elevation technique have been
subsequently proposed for the surgical procedures and grafting materials used. Many of the
sinus ﬂoor elevation techniques include the use
of grafting materials to ﬁll the subantral space,
aiming to maintain the volume created.
However, clinical studies on sinus ﬂoor elevation performed concomitantly with implant
placement have shown that the establishment of
an isolated space between the bone wall surface
and the sinus mucosa, resulted in spontaneous
formation of new bone, even without the use of
grafting materials.4–7 Moreover, the integrity of
the sinus membrane is known to be a prerequisite for success of the technique because it prevents the shift of the grafted material inside the
sinus cavity; shifting of the material may favor
acute or chronic infective complications and
possibly compromise bone regeneration.8 Another technique frequently adopted for sinus
ﬂoor elevation requires a crestal access,9 ﬁrst
carried out with the use of osteotomes and autologous bone as ﬁller material.10 The crestal approach may reduce the perforation of the sinus
membrane (4.7%)11 compared with the lateral
approach (44%).12

Several modiﬁcations of the crestal approach
have been subsequently proposed, aiming to elevate the sinus ﬂoor while maintaining the integrity of the Schneiderian membrane. For this
purpose, a variety of osteotomes, used with or
without bone ﬁllers,13, 14 or drills designed to
avoid membrane perforation,15 or the use of speciﬁc devices16, 17 or ultrasonic instruments18, 19
have been proposed. With the use of osteotomes, an elevation of the sinus membrane of
up to 10 mm in total may be obtained without
causing tearing.20 Another modiﬁcation of the
transcrestal approach was proposed21–23 based
on the principle of the edentulous ridge expansion technique.24 This approach includes the use
of a blade to perform the osteotomies and, subsequently, the use of blunt osteotomes.
The preservation of sinus walls appears to
have an important role in bone formation in the
sinus ﬂoor elevation procedure. In fact, in an experiment in monkeys on the early healing at elevated ﬂoor sinuses,25, 26 it was shown that new
bone only originated from the bone walls and
septa of the sinus. In that study, no evidence of
bone formation was observed from the sinus
mucosa, even though other studies have
demonstrated that the Schneiderian membrane
has the potential to produce bone.27–30 A minimum height of 4–6 mm of the sinus ﬂoor has
been suggested to guarantee the stability of the
implant and, consequently, the success of the
crestal access for sinus elevation.10, 31–35 When
the primary stability of an implant cannot be
guaranteed, a two-stage approach may be followed and implant placement would have to be
postponed for several months, depending on the
quality of the ﬁller material used.31–35 A twostage procedure has also been described for
sinus ﬂoor elevation through a crestal access using blades, osteotomes and a mallet.21 The aim
of the present study is to describe a minimally invasive two-stage technique for sinus ﬂoor elevation through a crestal access, using in both
stages a trapdoor prepared with the Sonosurgery system.

Materials & methods
The case of a patient who required oral rehabilitation by means of implants in the posterior maxillary area and presented with a widely pneumatized sinus was chosen to present the step-bystep procedure of the technique. The height of

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Figs. 1a–c

a

c

b

Figs. 2a–f

a

b

c

d

e

f
Figs. 3a–c

a

b

c
Figs. 4a–c

a

b
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c
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the sinus ﬂoor ranged between 2 mm and 4 mm,
depending on the outline of the base of the sinus.
It was not possible to guarantee implant primary
stability; thus, a two-stage approach was followed (Figs. 1a–c). Micro-cone beam computed
tomography (CBCT) scans (Kodak 9000, Carestream Health, Rochester, N.Y., U.S.) were taken
before surgery.
First stage of sinus floor elevation

A split-thickness flap was dissected using a
scalpel blade (BD Beaver 376400, BD Medical
Ophthalmic Systems, Waltham, Mass., U.S.). A
longitudinal incision was performed on the
alveolar crest 3–4 mm palatal to the center of
the crest. Short paramarginal releasing incisions were performed mesially (Fig. 2a). The
dissection of the flap at the buccal aspect was
extended up to the mucogingival junction, leaving only a thin layer of connective tissue on the
bone surface in order to better visualize the
bony crest morphology. After flap elevation, a
bone trapdoor was prepared with the use of a
vibrating sonic handpiece (Sonosurgery, TeKne
Dental, Calenzano, Italy) into which a straight
micro-saw (SFS 102, Komet Dental Gebr. Brasseler, Lemgo, Germany) had been inserted. The
trapdoor was produced in the center of the alveolar crest and was < 2.5 mm wide in the buccolingual plane. The bone incision was extended in
a mesiodistal direction for the entire edentulous
area to be treated. However, a safe distance of
about 1.5 mm from the premolar was maintained to avoid damaging the root (Figs. 2b–f).
The osteotomy of the bone trapdoor was
performed with a micro-saw 0.25 mm thick and
exercising minimal pressure, similar to that of a
pencil when writing (a maximum of 2–3 N).
These incisions on the bone were performed
with an external bevel, so that the bone trapdoor had a trapezoidal cross-section, the
largest base being at the cranial and the smallest at the caudal aspect of the trapdoor. A continuous movement along the incisions had to be
carried out by the operator using the sonic insert, gradually penetrating into the bone, until a
distinct change of material texture was perceived, indicating that the base of the sinus had
been reached. After that, the trapdoor was released along the osteotomies using a surgical
mallet on blunt chisels (KLS Martin Group,
Umkirch, Germany) with gentle taps (Fig. 3a).
Collagen sponges (Gingistat, GABA VEBAS,

Rome, Italy) were placed into the space obtained in order to prevent the Schneiderian
membrane from tearing, and these were subsequently pushed within the subantral space using the blunt chisels and mallet (Figs. 3b & c).
The 3-D hydraulic pressure produced by the
collagen soaked with blood encouraged the
sinus membrane detachment from the bone
walls. After sinus elevation, the buccal flap was
repositioned and sutured to the palatal aspect,
allowing a primary intention wound closure. A
CBCT scan with a low radiation dose was taken
immediately after the surgery (Figs. 4a–c).
Intra-oral radiographs were taken one, two and
three months after the first sinus elevation
(Figs. 5a–c).
Second stage of sinus floor elevation

Four months after the first surgical session, an
intra-oral radiograph was taken and assessed
(Fig. 5d). The radiographs showed that the
base of the sinus had gained about 3–4 mm in
height compared with the original situation,
yielding a total height of about 5–6 mm, which
could allow for primary implant stability. No
clinical signs of inflammation were observed. A
surgical procedure similar to that used in the
first stage was performed, including the mucosal incision. Again, a buccolingual crestal osteotomy < 2.5 mm wide was made (Figs. 6a & b).
The augmented dimensions of the sinus ﬂoor
compared with the initial situation allowed the
execution of deeper osteotomies with more pronounced bevels than those carried out during the
previous surgical stage. Consequently, the bone
trapdoor was higher and wider in the cranial
regions in comparison with that prepared in the
ﬁrst surgical stage.
Chisels of increasing thickness were used
to distract the bone toward the sinus, following
the incisions made with the sonic micro-saw.
This, in turn, meant that the chisels had a working direction with the same angulation as the
osteotomies. Once the trapdoor had been split
and mobilized by blunt chisels and a mallet,
both buccally and palatally from the parent
bone, collagen sponges were added and an implant with a conical shape (Pilot, Sweden &
Martina, Due Carrare, Italy) was placed
(Fig. 6c). The implant apex pushed the collagen
and the bone further, producing an additional
sinus floor elevation. Implant primary stability
was obtained by means of the pressure of the

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Figs. 1a–c
First sinus ﬂoor elevation
stage in the three planes.
In the initial CBCT scan, a
fracture of the second molar
and a periapical radiolucency
were observed. The
insufficient sinus ﬂoor height
in the ﬁrst molar position did
not allow for immediate
implant placement.
(a) Panoramic view.
(b) Cross-sectional view.
(c) Axial view.
Figs. 2a–f
Clinical view of the surgical
procedures. (a) Site after ﬂap
dissection and extraction
of the ﬁrst molar. The
osteotomies were performed
with an external bevel using a
micro-saw 0.25 mm thick and
exercising minimal pressure.
The bevel cuts were orientated
(b) mesially, (c) palatally,
(d) distally, and (e) buccally,
respectively. (f) The
osteotomies of the trapdoor
were ﬁnalized.
Figs. 3a–c
(a) The elevation of the
trapdoor and of the sinus ﬂoor
was performed with a surgical
mallet on blunt chisels.
(b) Collagen sponges were
placed into the space obtained,
and these were subsequently
pushed within the subantral
space using the blunt chisels
and mallet.
(c) Situation after the
placement of collagen
sponges.
Figs. 4a–c
A CBCT scan was taken
immediately after the surgery.
(a) Panoramic view.
(b) Cross-sectional view.
(c) Axial view.

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Figs. 5a–d

Figs. 5a–d

Radiographs showing the
healing (a) one, (b) two,
(c) three and (d) four months
after the ﬁrst sinus ﬂoor
elevation procedure.
Figs. 6a–d
Clinical view of the surgical
procedures of the second
sinus ﬂoor elevation. (a) Buccal
ﬂap elevated. (b) The trapdoor
was prepared, split and
mobilized from the parent
bone by chisels and a mallet.
(c) Collagen sponges were
added and an implant with
a conical shape was placed.
(d) The ﬂaps were sutured
with apical repositioning at
the buccal aspect.
Figs. 7a–c

a

b

c

d

Low-dose CBCT scan taken
immediately after the second
surgery. (a) Panoramic view.
(b) Cross-sectional view. (c)
Axial view.

Figs. 6a–d

a

b

c

d
Figs. 7a–c

a

b
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c
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implant collar on the walls of the access. The
Discussion
buccal and lingual flaps were sutured with apical repositioning at the buccal aspect (Fig. 6d). The surgical technique with a crestal trapdoor apA low-dose CBCT scan was taken immediately proach may present advantages over classical
sinus ﬂoor elevation performed through a lateral
after the second surgery (Figs. 7a–c).
window access. The crestal approach, conversely
to the lateral access, avoids opening large ﬂaps,
Prosthesis delivery and follow-up
performing long vertical releasing incisions, and
After four months of uneventful healing, impres- strong pulling on the ﬂaps during surgery. Moresions were taken and a metal–ceramic crown over, it allows for easier access to the distal zones
was fabricated and seated over the implant with less exposure of the surgical area.
The absence of biomaterial grafts, other than
(Figs. 8a–c). Checkups were performed during
the healing period and regularly up to three years the rapidly resorbable collagen sponge, deafterward. Intra-oral radiographs were taken im- creases the possible loss of material into the
mediately after prosthesis seating and yearly sinus and, consequently, the risk of infection in
case of unexpected perforation of the sinus muthereafter.
cosa. Moreover, no membranes are needed to
cover the access osteotomy, reducing the total
Results
biomaterial cost.36 The absence of grafted material allows a more reliable radiographic evaluaAfter three years, from the analyses of the CBCT tion of the progressive mineralization within the
scans, no marginal loss was found and bone was elevated area, whereas when a radiopaque graftobserved all around the implant surface. The lo- ing material is used, its radiopaque nature may
cation of the implant apex corresponded to the hinder the evaluation of bone formation.
new sinus ﬂoor (Figs. 9a–c). No complaints were
The use of a crestal access may avoid crossreported by the patient. At the clinical follow- ing the anastomosis between the posterior suups, no clinical signs of periimplant soft-tissue perior alveolar artery and the infraorbital arinﬂammation and no technical complications teries. This anastomosis may be quite large in
were noted during the three-year period of ob- diameter and may cause severe hemorrhages
servation (Fig. 9d).
when it is unintentionally damaged and possibly

Figs. 8a–c

Figs. 9a–d

c
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Figs. 8a–c
Clinical view of the outcome.
(a) Implant four months after
the second sinus ﬂoor
elevation. (b & c) Crown just
seated over the implant from
the occlusal and buccal views,
respectively.
Figs. 9a–d
Low-dose CBCT scan
taken after three years.
(a) Panoramic view.
(b) Cross-sectional view.
(c) Axial view.
(d) Clinical view.

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compromise the blood supply of the region.37–40
One of the most important advantages of the
present technique is, however, the presence of
intact bone walls, whereas in the lateral access
technique, the lateral wall is removed to a large
extent, compromising bone formation. In fact, it
has been shown that bone is formed from parent
bone, while the sinus mucosa does not contribute to such formation, at least during the
earliest periods of healing.25, 26 Finally, in the case
of thin alveolar ridges, a split-crest procedure
may be applied concomitantly, so that the width
of the ridge may also be augmented.
The crestal approach described in the present
article also has some disadvantages, such as the
low visibility within the elevated zone and the
complex learning curve. The chisels and mallet
have to be used carefully to avoid damage to the
sinus membrane and discomfort for the patient.
Moreover, the technique illustrated in the present article requires the sinus elevation to be performed twice, the implant being placed during
the second surgery.
The sonic handpiece instrument and the
micro-saw inserts used allow the operator to
perform sharp and thin incisions with a clear
view of the area, cleaned of bone smear and
blood by irrigation. Moreover, incision with vibrating tools weakens the bone along the lines of

the osteotomy, minimizing the use of the mallet
and consequently resulting in less discomfort for
the patient. Sonic instruments have been shown
to produce a very low increase in temperature
compared with ultrasonic instruments41 and very
limited soft-tissue damage.42–44 The use of sonic
instruments has been proposed for the extraction
of impacted canines45 and successfully tested for
implant placement in an animal experiment.46

Conclusion
The technique illustrated in the present article allowed the placement of implants of proper
length in a widely pneumatized sinus where the
bone height of the ﬂoor was insufﬁcient for immediate stabilization. After three years of function, neither marginal bone loss nor clinical signs
of inﬂammation were observed.

Competing interests
IA developed the Sonosurgery device and microsaw inserts used in the treatment of this case,
and hence declares a competing interest. DB declares that he has no competing interests in relation to this study. The study was self-funded by
the authors.

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Factors affecting primary stability of tapered implants with different thread design

Primary stability
of dental implants with different thread geometries placed by
clinicians with different clinical experience: An in vitro study
Abstract
Objective
Rafael Arcesio Delgado Ruiz,* José Luis Calvo Guirado,†
José Eduardo Maté Sánchez de Val,† Gerardo Gómez
Moreno,‡ Fawad Javed§ & Georgios Romanos*
School of Dental Medicine, Stony Brook University, N.Y.,
U.S.
†
International Dentistry Research Cathedra, Universidad
Católica San Antonio de Murcia, Murcia, Spain
‡
Faculty of Medicine and Dentistry, University of Granada,
Granada, Spain
§
School of Medicine and Dentistry, University of Rochester,
N.Y., U.S.

Corresponding author:
Prof. Rafael Arcesio Delgado Ruiz
School of Dental Medicine
11 Westchester Hall
Stony Brook NY 11794-8712
USA
T +1 631 786 1839
F +1 631 631 6931
rafael.delgado-ruiz@stonybrookmedicine.edu

The objective of this study was to establish the primary stability of implants
with two different designs placed into artificial bone (Type II and Type IV
density) by clinicians with different levels of experience using the same
implant bed preparation protocol.
Materials and methods

An in vitro experiment was performed using polyurethane resin bone blocks
resembling Type IV and Type II bone density. Eighty control implants (Replace Select Tapered with symmetric threads, Nobel Biocare) and 80 test
implants (NobelActive, tapered with progressive threads, Nobel Biocare)
were placed. The implant diameter was 4.3 mm and the length was
11.5 mm for both groups. Implant beds were prepared by two clinicians
with different levels of experience (expert and intermediate), and subsequently implants were placed with the platforms at crestal level. The stability parameters of insertion torque and implant stability quotient were
recorded when the implants reached the insertion depth. A two-way ANOVA was used to evaluate differences within the groups; multiple comparisons were performed using the Tukey test. Significance was set at p < 0.05.

How to cite this article:
Delgado Ruiz RA, Calvo Guirado JL, Maté Sánchez de Val JE,
Gómez Moreno G, Javed F, Romanos G. Primary stability
of dental implants with different thread geometries placed
by clinicians with different clinical experience: an in vitro
study.
J Oral Science Rehabilitation.
2016 Mar;2(1):48–55.

Results

Stability parameters were significantly higher for Type II bone for both
clinicians compared with Type IV bone (p < 0.05). Implants with a progressive thread design showed a tendency to increased stability compared with
implants with a symmetric thread design in Type IV bone (p < 0.05). The
clinicians’ level of experience did not affect the implant stability (p > 0.05).
Conclusion

Within the limitations of this in vitro study, the following conclusions were
drawn:
- The clinician’s level of experience does not affect the implant stability in Type
IV and Type II bone when the same implant bed preparation protocol is used.
- The stability of tapered implants with symmetric threads and those with
progressive threads is increased in Type II bone density.
- The implant stability in soft bone is similar for tapered implants with a symmetric thread design and for those with a progressive thread design.
Keywords

Implant design, implant stability, soft bone, hard bone, level of experience.

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Factors affecting primary stability of tapered implants with different thread design

Introduction

Figs. 1a & b

Dental implant stability is important for achieving osseointegration. The implant body design
and the thread geometry are significant for improvement of the mechanical implant stability.
Tapered implants appear to have better mechanical stability than do parallel-walled implants.1
A study comparing the insertion torque of tapered and of cylindrical implants has shown that
tapered implants are associated with higher
primary stability than are cylindrical implants.2
In an experimental study on dogs, Kim et al.
compared the mechanical properties of tapered
and parallel-walled implants in terms of success
rates.3 Maximum insertion torque and maximum
removal torque were assessed. The results
showed significantly higher values of maximum
insertion torque and maximum removal torque
for tapered implants than for parallel-walled
implants. In addition, use of cylindrical nonthreaded implants has been associated with a
higher implant failure rate compared with
threaded implants.4 Moreover, it has been postulated that tapered implants have a better load
distribution to surrounding bone by mimicking
the natural root form.5
The implant body design and the thread geometry have been compared in a multicenter clini
cal study with immediate loading protocols.
Different implant designs, such as tapered implants with a symmetric thread design (NobelReplace Tapered Groovy), tapered implants with
a progressive thread design (NobelActive internal connection), and cylindrical implants with
the same thread profile as the NobelActive internal connection but with a narrow neck
(NobelActive external connection), presented a
similar cumulative survival rate after three years
of loading.6 In addition, the bone condensation
technique in cancellous bone and other surgical
techniques may influence implant stability.7
The quality of the osteotomy might be influenced by the clinician’s surgical experience1, 8
and therefore the primary stability could be

Figs. 1a & b

a

Synthetic bone blocks used
in the experiment.
(a) Type II dense bone.
(b) Type IV soft bone.

b

affected. There is a lack of studies in the literature
evaluating primary stability and its relation to
surgical experience. Therefore, the aim of this
study was to evaluate the primary stability of two
implant designs with different thread geometries
placed by two clinicians with different levels of
clinical experience in implant surgical procedures
and placed into two different bone qualities.
Materials & methods
Two surgeons with different levels of experience
performed the drilling: expert (GR, 25 years’ experience in implant dentistry, had placed more
than 10,000 implants) and intermediate (RD, 15
years’ experience in implant dentistry, had placed
fewer than 5,000 implants). The implant bed on
synthetic bone blocks was prepared for two different implant designs: Replace Select Tapered
regular platform (Nobel Biocare, Gothenburg,
Sweden), a tapered implant with a symmetric
thread design (TST) and conical connection; and

Table 1

Table 1
Mechanical properties

Block of Type II density

Block of Type IV density

Compressive yield strength

31.0 MPa

2.30 MPa

Compressive modulus

0.759 GPa

0.032 GPa

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Mechanical properties of the
synthetic blocks used in the
experiment.

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Factors affecting primary stability of tapered implants with different thread design

Implants
placed

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7

Group 8

n = 40

N = 320

ISQ value
(mean ± S.D.)

63 ± 4e, f, g, h

63 ± 3e, f, g, h

65 ± 3e, f, g, h

65 ± 5e, f, g, h

54 ± 3

59 ± 2e, g

53 ± 2

58 ± 1e, g

Implants
placed

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7

Group 8

n = 40

N = 320

IT value
(mean ± S.D.
in N cm)

40 ± 2e, f, g, h

42 ± 4e, f, g, h

41 ± 5e, f, g, h

43 ± 2e, f, g, h

18 ± 2

20 ± 1

17 ± 2

19 ± 1

Table 2
Differences in primary stability
were observed between
different bone densities and
between different implant
designs in terms of ISQ. The
Tukey multiple comparison
test showed differences
favoring higher stability in
Type II bone density compared
with Type IV. Regarding
implant design, implants with
a progressive thread design in
Type IV bone density favored
higher stability. There were no
differences in implant stability
regarding level of experience.

Table 3
Differences in primary stability
were observed between
different bone densities in
terms of IT. The Tukey multiple
comparison test showed
differences favoring higher
stability in Type II bone density
compared with Type IV.
Regarding implant design and
level of experience, there were
no differences in implant
stability.

NobelActive regular platform (Nobel Biocare), a
tapered implant with a progressive thread design
(TPT) and conical connection. The implant diameter of 4.3 mm and length of 11.5 mm were used
for all groups.
For this experimental controlled study, two
synthetic bone blocks (Sawbones, Pacific Research Laboratories, Vashon Island, Wash., U.S.)
measuring 13 cm × 18 cm × 4 cm, with two different densities (Type II and Type IV), were used
(Figs. 1a & b). The Type II solid block was of 0.85
± 0.4 g/cm3 in density and the Type IV cellular
block was of 0.45 ± 0.10 g/cm3 in density. The
mechanical properties of the artificial blocks used
in the study are presented in Table 1.

Drilling procedures

The blocks were fixed to a metallic platform to
reduce movement during drilling, as well as to
ensure the same experimental conditions for both
operators. The drilling protocol used was recommended by the manufacturer and was performed
by a calibrated operator. Instructions were provided to both clinicians regarding the manner in
which they were to prepare the implant bed.
During drilling, an in-and-out motion and drilling
in the bone for 1–2 s without stopping the handpiece motor were performed until the drill
reached the depth reference line (11.5 mm). The
drilling parameters were the same for both operators: drilling speed of 800 rpm with no irrigaEight experimental groups were created as follows: tion, and the drills were replaced after ten uses
Group 1: Expert + Type II blocks + TST
as recommended by the manufacturer.
Group 2: Expert + Type II blocks + TPT
– Drilling for the Replace Select Tapered implant
Group 3: Intermediate + Type II blocks + TST
in Type II and Type IV bone: The drilling started
Group 4: Intermediate + Type II blocks + TPT
Group 5: Expert + Type IV blocks + TST
with the 2.0 mm diameter pilot drill, followed
by the 3.5 mm diameter tapered drill and
Group 6: Expert + Type IV blocks + TPT
finished with the 4.3 mm tapered drill.
Group 7: Intermediate + Type IV blocks + TST
Group 8: Intermediate + Type IV blocks + TPT. –Drilling for the NobelActive implant in Type IV
bone (soft-bone protocol): The drilling started
with the 2.0 mm diameter drill, followed by a
A total of 320 perforations were performed, 160
perforations on each block. The allocation of
stepped drill with 2.4/2.8 mm diameter steps
and finished with a stepped drill with 2.8/3.2
samples to groups was performed according to
9
mm diameter steps.
randomization software (Research Randomizer),
and after the allocation each one of the eight – Drilling for the NobelActive implant in Type II
bone (hard-bone protocol): The drilling started
groups was composed of 40 samples (Fig. 2).

50 Volume 2 | Issue 1/2016

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Table 2

Table 3

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Factors affecting primary stability of tapered implants with different thread design

Fig. 2

with the 2.0 mm diameter drill, followed by The implants were then retrieved and placed into
a stepped drill with 2.4/2.8 mm diameter steps the hard bone for the evaluation of primary staand finished with a stepped drill with 3.2/3.6 mm bility. A total of 320 evaluations were performed.
diameter steps.
Primary stability evaluation

Fig. 2
Study design scheme for the
320 implant beds prepared in
synthetic bone blocks with
different bone densities.

Implant characteristics

The evaluation of primary stability was performed
– Replace Select Tapered: This implant possess- according to the insertion torque (IT) and the imes a conical profile with the same thread profile. plant stability quotient (ISQ) as follows:
The body is tapered, the neck has micro-threads
and the connection is conical (Fig. 3b).
- IT was measured during implant insertion by
– NobelActive: This implant possesses a vari- the implant motor (DENTSPLY, Waltham,
able-thread profile, wider (vertically) and short- Mass., U.S.) and was recorded in N cm. The
er (horizontally) as it progresses from the neck peak values were reached when the implant
area, in which there are micro-threads. In the platform was located at the surface of the bone
apical region, the implant has a pronounced block (11.5 mm). Each placed implant resulted
tapered body with sharp threads to facilitate in a single value, and mean values were collatinsertion and cutting of unprepared bone. The ed by group and compared.
connection is conical and the coronal region is - ISQ was recorded using resonance frequency
back-tapered coronally, which results in a analysis with the Osstell Mentor device (Osstell, Göteborg, Sweden). Specific transducers
reduction of the platform diameter (Fig. 3a).
were used, and replaced after ten uses until all
Implant placement
of the measurements had been performed.
Measurements were taken as follows: The
A total of 160 implants were placed in a random transducer was screwed to the placed implant.
scheme in 320 implant bed preparations, until The probe was laterally oriented in relation to
they reached the crestal level, leaving the implant the transducer and measurements were taken.
platforms flush with the block surface (Fig. 4). Each measurement was repeated in triplicate
The implants were placed first into the soft bone and mean values were recorded. All measureand primary stability was evaluated afterwards. ments were performed by an independent,

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Factors affecting primary stability of tapered implants with different thread design

Figs. 3a & b

Fig. 3

Implant designs used for the
implant stability evaluation.
(a) Tapered implant with a
symmetric thread design.
(b) Tapered implant with a
progressive thread design.

a

b

unbiased examiner. Data were expressed as the tapered implants with a progressive thread
ISQ values (1–100). Mean values were collated design had increased primary stability in soft
by group and compared.
bone compared with the tapered implants with
a symmetric thread design for different evaluation groups (Groups 5, 6, 7 and 8; p < 0.05). HowStatistical analysis
ever, within the dense bone groups, no significant
The statistical analyses were performed with differences in terms of stability were found for
SPSS software (Version 13.0; SPSS, Chicago, Ill., the two implant thread designs (Groups 1, 2, 3
U.S.). For the evaluation of the normality distri- and 4; p > 0.05). The evaluation by IT values did
butions of each group, the Shapiro–Wilk test was not show differences in stability in soft bone
used. A two-way ANOVA was used to evaluate (p > 0.05; Tables 2 & 3).
differences within groups and the impact of the
Regarding the effects of the operator’s level
operator on the stability parameters. Multiple of experience on the implant stability, no statiscomparisons were performed using the Tukey tically significant differences were observed
test. Significance was set at p < 0.05. Data were between the implant groups in IT or ISQ values
expressed as mean value ± S.D. and ranges were (p > 0.05; Tables 2 & 3).
calculated for each group.
Results
All of the implants were mechanically stable, but
implant stability differed between groups. Regarding bone density, the results showed higher
stability (p < 0.05) evaluated by ISQ in dense
bone (Groups 1, 2, 3 and 4) compared with soft
bone (Groups 5, 6, 7 and 8). Regarding the effects
of the implant design, the results showed that

52 Volume 2 | Issue 1/2016

Discussion
Some authors consider that the implant survival rate is higher for experienced clinicians,10–13
while others have found similar cumulative implant survival rates independent of the clinicians’
level of experience.14, 15
However, there is a lack of research in the
literature regarding the effect of level of experience on primary stability; therefore, the present

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Factors affecting primary stability of tapered implants with different thread design

Fig. 4

Fig. 4

Implant insertion level for the
evaluation of the IT and the
ISQ values. The implants were
placed with the most coronal
portion of the platform flush
with the block surface.

in vitro study compared the primary stability of
implant designs with symmetric or progressive
threads in soft and hard bone placed by clinicians
with different levels of surgical experience.
There is great variability in the definition of
level of experience used in previous studies.
Lambert et al. regarded an experienced clinician
as one who had placed more than 50 implants
and an inexperienced one as having placed fewer
than 50 implants.13 Preiskel and Tsolka consider
ed experienced clinicians those periodontists
and oral and maxillofacial surgeons with more
than two years of experience with dental implants and they considered as inexperienced
those oral and maxillofacial surgeons just beginning their involvement in dental implants.16
Hinckfuss et al. classified level of experience as
novice (dental students with no clinical surgical
implant experience who had completed an in
structional laboratory course in placing implants
in typodonts), intermediate (graduate periodontology residents who had placed between 20
and 80 implants clinically) and experienced

(periodontists who had placed over 300 implants clinically).17
The present experimental study assigned to
the surgeons two levels of experience: expert (25
years’ experience in implant dentistry and more
than 10,000 implants placed) and intermediate
(15 years’ experience in implant dentistry and
fewer than 5,000 implants placed). Compared
with other studies, this is one of the strictest
measurements of clinician experience. The ratio
nale is based on a study in psychology that demonstrated that level of experience is determined, among others, by learning (skills acquired
through repetition) and performance (quality of
the procedures that is dependent on the performer);18 therefore, it can be asserted that the number of years of experience and the number of
procedures performed used in the present exper
iment are reasonable.
The results of the present work showed that
the effects of the thread design were beneficial
for primary stability, especially in the soft bone,
as measured by ISQ value and that there was no

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significance in the final implant stability regarding the two clinicians’ levels of experience for
both bone qualities (soft and hard bone) and the
two implant designs.
The IT values were not conclusive for differ
ences between implant design and primary stability. Apparently, the sensitivity of the ISQ meter
is able to detect very small differences,19 while IT
underestimates the stability values. The motor
used for the evaluation of IT in this experimental
study operates in increments of 5 N cm; therefore,
values below 5 N cm can be underestimated.
However, the implants used had a tapered
shape and this may be the main reason that the
stability of the implants was similar (p > 0.05).
Previous studies have shown that implants with
symmetric threads and a cylindrical or tapered
implant body shape have different primary stability when they are placed in soft bone (parallel-walled implants have lower stability) and the
clinician’s level of experience appears to be important.1, 8 The data in this study confirm that the
tapered implant design used (Replace Select
Tapered and NobelActive) may achieve excellent
stability for clinicians with different levels of experience in an experimental set.
A recent study comparing the survival rates
of dental implants placed in a residency program
under direct supervision for the treatment of
patients with overdentures has shown a high
survival rate of 97.7% within a period of two
years.20 The researchers concluded that novice
general dentistry residents can successfully
place mandibular implants and restore them with
overdentures under direct supervision, resulting
in subsequent enhancement of the patients’
satisfaction with their mandibular dentures.
However, new clinical trials by a national
group of dental practitioners presented higher
failure rates for implants placed by general dentists compared with those for implants placed
by clinicians with specialty training.21 For other
studies, experience was defined as number of
implants placed, and clinical studies showed
that those clinicians (n = 1,260) with experience
of placing fewer than 50 implants presented a
higher failure rate of 3.5%, compared with surgeons (n = 1,381) with greater surgical experience (50 or more implants), who showed
a failure rate of 1.8%.13
There is no doubt that primary stability of
dental implants is of significant importance for
achieving long-term success, especially when
implants are loaded immediately after place-

54 Volume 2 | Issue 1/2016

ment.22 The mechanical stability of the implant
is very important, particularly in soft bone, and
the thread design may provide better mechanical
anchorage in the surrounding bone. A previous
study evaluating implant stability based on the
thread pitch width showed that implants with a
narrow thread pitch had a higher stability owing
to the greater surface area, compared with implants with a wider thread pitch when they were
placed in cancellous bone.23
Conclusion
Within the limitations of this in vitro study, the
following conclusions can be drawn:
- The operator’s level of experience, expert versus
intermediate, does not affect the implant stability in Type IV and Type II bone when the same
implant bed preparation protocol is used.
- The stability of tapered implants with symmetric threads and those with progressive threads
is increased in Type II bone density.
- The implant stability in soft bone is similar for
tapered implants with a symmetric thread design and for those with a progressive thread
design.
Competing interests
The authors declare that they have no competing
interests related to this study. No financial support was received for this study.

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Urbaniak GC, Plous S. Research
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Moraschini V, Velloso G, Luz D, Porto
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Coronally advanced flap in the treatment of bilateral multiple gingival recessions

The coronally advanced flap in the treatment of bilateral
multiple gingival recessions with or without tunneling the
maxillary midline papilla: A randomized clinical trial
Roberto Abundo,*† Giuseppe Corrente,*†
Michele Perelli,* Carlo Saccone,* Marta Zambelli*
& Hector L. Sarmiento†‡
Private practice, Turin, Italy
epartment of Periodontics,
D
School of Dental Medicine, University
of Pennsylvania, Philadelphia, Pa., U.S.
‡
Private practice, New York, U.S.

*
†

Corresponding author:

How to cite this article:

Dr. Roberto Abundo
Corso Sicilia, 51
10137 Turin
Italy

Abundo R, Corrente G, Perelli M, Saccone C,
Zambelli M, Sarmiento HL. The coronally advanced
flap in the treatment of bilateral multiple gingival
recessions with or without tunneling the maxillary
midline papilla: a randomized clinical trial.

T +39 011 0467000
F
+39 011 6618378
robabund@yahoo.it

J Oral Science Rehabilitation.
2016 Mar;2(1):56–61.

Abstract
Objective

The objective of this study was compare the clinical results of
the coronally advanced flap (CAF) without vertical releasing
incisions using (i) a tunneling procedure on the maxillary midline papilla (test) or (ii) a conventional technique (control) in
which the midline papilla is incised and elevated like any other
papilla in the procedure.
Materials and methods

Twenty healthy subjects with at least two Miller Class I gingival recessions (RECs) crossing the midline in the maxilla were
enrolled for the study. Fifty-six (mean initial REC = 2.3 ± 0.9 mm)
and 75 (mean initial REC = 2.3 ± 1.1 mm) RECs were treated in
the test and control groups, respectively. All of the cases were
treated by means of CAF without vertical releasing incisions:
ten were randomly assigned to the test group and ten to the
control group. Clinical evaluations in terms of REC were performed at baseline (preoperative) and after one year. Differences in REC reduction (RECred) and in complete root coverage
(CRC) between the two groups were statistically analyzed both
for all of the RECs of each treatment group and for the central
incisors only.

The initial mean REC at the central incisors was 2.3 ± 0.9 mm
and 2.7 ± 1.2 mm, respectively, for the test and control groups.
The mean final REC after 12 months was 0.3 ± 0.6 mm and
0.4 ± 0.6 mm, respectively, for the test and control groups with
a RECred from the baseline of 2.0 ± 0.9 mm (87%) for the test
group and of 2.3 ± 1.0 mm (87%) for the control group. Fifteen
out of 20 (75%) RECs in the test group and 14 out of 20 (70%)
in the control group achieved CRC.
Conclusion

There was no statistically significant difference between the
two groups for RECred and CRC for either all of the RECs or
those at the central incisors only. CAF performed with tunneling of the midline papilla is a safe procedure that shows similar
results to conventional CAF surgery.
Keywords

Coronally advanced flap, gingival recession, papilla tunneling,
mucogingival surgery, dental esthetics.

Results

The mean final REC at 12 months for the test group was
0.3 ± 0.5 mm and for the control group 0.4 ± 0.6 mm, with a
RECred of 2.1 ± 0.9 mm (89.1% of the initial REC) and of
1.9 ± 0.9 mm (84.3% of the initial REC), respectively. Forty-three out of 56 (76.8%) RECs in the test group and 53 out
of 75 (70.7%) in the control group achieved CRC.

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Coronally advanced flap in the treatment of bilateral multiple gingival recessions

Introduction

Materials & methods

The coronally advanced flap (CAF) is a surgical
procedure for treating gingival recessions (RECs)1
by advancing the residual keratinized tissue sur
rounding an exposed root to cover the cemento
enamel junction. It can be used alone or in com
bination with a connective tissue graft,2 an
enamel matrix derivative3 or various connective
tissue graft substitutes,4, 5 especially when kera
tinized tissue limiting the REC is not adequate to
allow stable results.
It can be performed on multiple adjacent root
exposures and can be considered the technique
of choice for such a clinical purpose,6 with speci
fic advantages when treating gingival RECs in
esthetic areas. On multiple adjacent RECs, CAF
can even be performed without vertical releasing
incisions7 with increased possibility of achieving
complete root coverage (CRC), better esthetic
results owing to the complete absence of keloid
aspects sometimes shown after healing of the
vertical releasing incisions and a better post
operative course for the patient.8
A modified approach was introduced in the
treatment of bilateral gingival RECs in the es
thetic area using CAF.9 Later, other authors10, 11
described a minimally invasive technique for the
management of the papilla situated between the
central incisors using the tunneling approach to
advance a flap for covering either a subepithelial
connective tissue graft or a substitute graft in
association with a specific flap design.12 A tunnel
can be surgically created underneath the buccal
aspect of the midline papilla, allowing the mobi
lization of the gingival margin on both the adja
cent central incisors and maintaining postopera
tive ideal soft-tissue stability.
The aim of the present study is to compare
the results obtained at one-year clinical follow-up
in the treatment of multiple Miller Class I gingi
val RECs of the maxillary esthetic area, using CAF
with the papilla tunneling technique or with the
conventional technique. Furthermore, the aim is
to compare the specific results obtained at the
buccal aspect of the maxillary central incisors
with CAF and the maxillary midline papilla tun
neling technique and with the conventional CAF
technique.

Twenty subjects with multiple maxillary bilater
al gingival RECs in the area between the left sec
ond premolar and the right second premolar (at
least two adjacent teeth with Miller Class I REC
with at least 2 mm of residual keratinized tissue
and at least one such tooth on each side of the
maxilla), 11 females and 9 males (age range of
22–60) in good general health were selected.
After the first examination, all of the patients
underwent a single session of prophylaxis with
instructions on proper oral hygiene techniques,
scaling and professional tooth cleaning by means
of rubber cups and prophylaxis paste.
Further examinations were scheduled once
each patient was able to demonstrate adequate
supragingival plaque control with an effective
and atraumatic brushing technique. At baseline,
immediately prior to surgery, for each tooth in
volved in the treatment, REC was measured from
the cementoenamel junction to the gingival mar
gin and residual keratinized tissue apical to each
REC was measured from the gingival margin to
the mucogingival junction. Probing pocket depth
was measured on the mesial and distal aspects
of each tooth involved in order to identify Miller
Class III RECs that would not be evaluated. RECs
with residual keratinized tissue of less than 2 mm
at baseline were treated during surgery but exclu
ded from the evaluation. A sequence of randomi
zation was generated by a subject not involved
in the research, instructed to randomly place ten
sheets of paper bearing “tunneling” and ten
“no tunneling” inside 20 progressively numbered
envelopes.
The surgical protocol was the following: After
local anesthesia (articaine with 1:100,000
epinephrine), exposed roots were gently instru
mented by means of Gracey curettes and rotating
diamond burs mounted on a micromotor hand
piece. The envelope was then opened in order to
determine whether the surgical design of the flap
was to be performed according to a tunneling
procedure on the midline papilla or whether con
ventional CAF was to be performed. In the case
of conventional CAF, the flap was designed with
marginal and papillary incisions performed with
a #15C blade, according to the CAF technique for
monolateral multiple RECs7 without vertical re
leasing incisions, ideally dividing the right and the
left sequence of RECs located at each side of the
midline as an independent monolateral root
coverage procedure with its centre of rotation on

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Coronally advanced flap in the treatment of bilateral multiple gingival recessions

Figs. 1 & 2

Figs. 3 & 4

Fig. 1

Fig. 5

Test case: Preoperative
situation.
Fig. 2
Test case: Postoperative
situation after CAF performed
with a tunneling procedure on
the midline papilla.
Fig. 3
Test case: Clinical situation
at seven days, immediately
after suture removal.
Fig. 4
Test case: Clinical situation
at two months.
Fig. 5
Test case: Clinical situation
at one year.

the homolateral canine.12 In tunneling cases, the
midline papilla was tunneled with a dedicated
instrument (stoma periosteal elevator for tunne
ling, 2 mm, Storz am Mark, Emmingen-Liptingen,
Germany), while in conventional CAF cases, two
incisions were carried out on the midline papilla,
outlining the surgical papilla that was subsequent
ly elevated. Thereafter, the flap was raised with a
sequence of split-thickness dissection of the pa
pillae, followed by a full-thickness elevation almost
2 mm apical to the mucogingival junction and by
a split-thickness dissection in the superficial layers

58 Volume 2 | Issue 1/2016

of the muscles underneath the alveolar mucosa
until a passive coronal displacement of the flap
was obtained. The residual epithelium covering
the papillae in the portion coronal to the oblique
incisions outlining the surgical papillae in the flap
was then removed by means of a #15C blade. In
every case in which during surgery a frenum was
considered detrimental for the final result, a mini
mal frenectomy was performed.
The flap was then secured in a coronal posi
tion, covering the cementoenamel junction of
each involved tooth by suturing the papillae with

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Table 1

Table 1

Test (tunnel; n = 56)
Mean ± S.D.

Control (no tunnel; n = 75)
Mean ± S.D.

Initial recession (mm)

2.3 ± 0.9

2.3 ± 1.1

Final recession (mm)

0.3 ± 0.5

0.4 ± 0.6

Recession reduction (mm)

2.1 ± 0.9

1.9 ± 0.9

Recession reduction:
Comparison between the test
and control groups.

Table 2

Table 2

Complete root coverage

Incomplete root coverage

Total

Test (tunnel)

43

13

56

Control (no tunnel)

53

22

75

Total

96

35

131

Table 3

Test (tunnel; n = 20)
Mean ± S.D.

Control (no tunnel; n = 20)
Mean ± S.D.

Initial recession (mm)

2.3 ± 0.9

2.7 ± 1.2

Final recession (mm)

0.3 ± 0.6

0.4 ± 0.6

Recession reduction (mm)

2.0 ± 0.9

2.3 ± 1.0

Complete root coverage:
Comparison between the test
and control groups.

Table 3
Recession reduction of central
incisors: Comparison between
the test and control groups.

Table 4

Table 4

Complete root coverage

Incomplete root coverage

Total

Test (tunnel)

15

5

20

Control (no tunnel)

14

6

20

Total

29

11

40

synthetic monofilament 5-0 sutures (Monomyd,
Butterfly Italia, Cavenago di Brianza, Italy; POLI
NYL, Sweden & Martina, Due Carrare, Italy; Cyto
plast, Osteogenics Biomedical, Lubbock, Texas,
U.S.). In the postoperative period, ketoprofen
(OKi, Dompé, Milan, Italy) according to the pati
ent’s need was prescribed for pain control. Pati
ents were instructed to abstain from consuming
hot food and beverages for two days and from
chewing hard food in the area of intervention
until suture removal. Equally, no flossing or
brushing around the treated teeth was allowed
and a 0.12% chlorhexidine spray (CURASEPT ADS
Spray, Curaden, Saronno, Italy) was prescribed
for local application t.i.d. after meals. After suture
removal, proper oral hygiene measures were
re-established, starting with brushing with an
ultrasoft postoperative toothbrush. Furthermore,
examinations were scheduled for 2, 4, 8 and 12
months, measuring again all preoperative clinical
parameters at the 12-month control (Figs. 1–5).
REC reduction (RECred) and the CRC rate for the

test and control groups were calculated for all
teeth involved in the treatment and for the cen
tral incisors adjacent to the midline papilla. Dif
ferences in terms of RECred and the CRC rate
between the test and control groups were deter
mined according to statistical analysis for all of
the RECs by means of the Student’s t-test for
independent samples and the chi-squared test,
respectively, and limited to those at the central
incisors by the Mann–Whitney U test and Fisher
exact test, respectively. A p-value of < 0.05 was
considered statistically significant.
Results
Fifty-seven Miller Class I RECs were treated in
the test group and 76 in the control group. One
REC exhibiting less than 2 mm of residual kera
tinized tissue in each group received a connective
tissue graft or a graft substitute and was not
considered in the study. Therefore, 56 (mean

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Complete root coverage of
central incisors: Comparison
between the test and control
groups.

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Coronally advanced flap in the treatment of bilateral multiple gingival recessions

initial REC = 2.3 ± 0.9 mm) and 75 (mean initial
REC = 2.3 ± 1.1 mm) RECs were analyzed for each
treatment group.
The mean final REC at 12 months was
0.3 ± 0.5 mm for the test group and 0.4 ± 0.6 mm
for the control, with a RECred of 2.1 ± 0.9 mm
(89.1% of the initial REC) and 1.9 ± 0.9 mm
(84.3% of the initial REC), respectively. The Stu
dent’s t-test for unpaired data did not find a sta
tistically significant difference in RECred bet
ween the two groups (p = 0.9692; Table 1).
Forty-three out of 56 (76.8%) RECs in the test
group and 53 out of 75 (70.7%) in the control
group achieved CRC. The chi-squared test did not
demonstrate a statistically significant difference
in the CRC rate between the two groups (p =
0.4336; Table 2).
Table 3 shows the data of the RECs at the
central incisors adjacent to the tunneled or not
tunneled papilla. The initial mean REC at the cen
tral incisors was 2.3 ± 0.9 mm and 2.7 ± 1.2 mm,
respectively, for the test and control groups. The
mean final REC after 12 months for the test and
control groups was 0.3 ± 0.6 mm and 0.4 ± 0.6 mm,
respectively, with a RECred from the baseline of
2.0 ± 0.9 mm (87%) for the test and 2.3 ± 1.0 mm
(87%) for the control groups. The Mann–Whitney
U test did not show a statistically significant dif
ference in RECred between the two groups (p =
0.27572; Table 3). Fifteen out of 20 (75%) RECs
in the test group and 14 out of 20 (70%) in the
control achieved CRC. The Fisher exact test did
not find a statistically significant difference in the
CRC rate between the two groups (p = 0.7401;
Table 4).

on monolateral RECs (97.0%)7 or in a limited
number of patients and RECs (97.0%).9 In this
study, CRC too (76.8%) was comprised in the
upper level of the range of outcomes of overall
periodontal plastic procedures (23.8–89.3%)6
and showed better results than CRC obtained
with conventional CAF with no releasing incisions
in the same esthetic area (61.0%)13 but worse
than the outcomes obtained both with improved
CAF (84.6%)13 and CAF alone (84.0%; 88.0%;
89.0%)14, 7, 9 even within the above-mentioned
limits of these last two studies.
It is important to emphasize that no previous
investigation has evaluated either cases of bila
teral root exposures exclusively or such a large
number of consecutive RECs per patient (mean
of 6.55) as in the present study. In the previously
mentioned clinical studies,7, 9, 14 the number of
consecutive RECs that underwent treatment
varied with a mean of between 3.3 and 4.1 per
patient. Even considering only the central
incisors, the results of CAF with the tunneling
procedure were better in terms of RECred and
CRC than those of the control group were, al
though such a difference did not achieve stati
stical significance in this case. No comparison is
possible with other investigations concerning
specific data on these teeth, since the key role of
this method in the symmetry and esthetics of the
smile has not been reported in literature prior to
this study.
Conclusion

CAF performed with tunneling of the maxillary
midline papilla can be considered a minimally
invasive, safe and predictable surgical procedure,
Discussion
but failed to demonstrate significant additional
The results of CAF performed with a tunneling benefits in terms of RECred and CRC compared
procedure underneath the maxillary midline with a conventional approach in this randomized
papilla were better in terms of RECred than those clinical trial.
of the control group, although the differences did
not achieve statistical significance. They were
Competing interests
89.6% aligned with the outcomes of overall peri
odontal plastic procedures from a recent system
atic review of the literature (86.27%)6 and with The authors declare that they have no competing
those from another publication on CAF with no interests. The study was self-funded by the au
releasing incisions in the same esthetic area thors.
(89.1%).13 However, limited to the same esthetic
area, they were slightly inferior to those of both
CAF improved with an orthodontic device for a
sling suture and flap securing in a more coronal
position (96.2%)13 and CAF alone (95.0%),14 even

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References
1.
Allen EP, Miller PD Jr. Coronal positioning
of existing gingiva: short term results in
the treatment of shallow marginal tissue
recession.
→ J Periodontol.
1989 Jun;60(6):316–9.
2.
Nelson SW. The subpedicle connective
tissue graft. A bilaminar reconstructive
procedure for the coverage of denuded
root surfaces.
→ J Periodontol.
1987 Feb;58(2):95–102.
3.
Modica F, Del Pizzo M, Roccuzzo M,
Romagnoli R. Coronally advanced flap for
the treatment of buccal gingival recessions
with and without enamel matrix derivative.
A split-mouth study.
→ J Periodontol.
2000 Nov;71(11):1693–8.
4.
Harris RJ. A comparative study of root
coverage obtained with an acellular dermal
matrix versus a connective tissue graft:
results of 107 recession defects in 50
consecutively treated patients.
→ Int J Periodontics Restorative Dent.
2000 Jan-Feb;20(1):51–9.

5.
McGuire MK, Scheyer ET. Xenogenic
collagen matrix with coronally advanced
flap compared to connective tissue with
coronally advanced flap for the treatment
of dehiscence-type recession defects.
→ J Periodontol.
2010 Aug;81(8):1108–17.
6.
Graziani F, Gennai S, Roldán S, Discepoli N,
Buti J, Madianos P, Herrera D. Efficacy of
periodontal plastic procedures in the
treatment of multiple gingival recessions.
→ J Clin Periodontol.
2014 Apr;41 Suppl 15:S63–76.
7.
Zucchelli G, De Sanctis M. Treatment of
multiple recession-type defects in patients
with esthetic demands.
→ J Periodontol.
2000 Sep;71(9):1506–14.

8.
Zucchelli G, Mele M, Mazzotti C,
Marzadori M, Montebugnoli L, De Sanctis
M. Coronally advanced flap with and
without vertical releasing incisions for the
treatment of multiple gingival recessions:
a comparative controlled randomized
clinical trial.
→ J Periodontol.
2009 Jul;80(7):1083–94.
9.
Zucchelli G, De Sanctis M. The coronally
advanced flap for the treatment of multiple
recession defects: a modified surgical
approach for the upper anterior teeth.
→ J Int Acad Periodontol.
2007 Jul;9(3):96–103.
10.
Zuhr O, Fickl S, Wachtel H, Bolz W,
Hürzeler MB. Covering of gingival
recessions with a modified microsurgical
tunnel technique: case report.
→ Int J Periodontics Restorative Dent.
2007 Sep-Oct;27(5):457–63.

12.
Abundo R, Corrente G. Chirurgia plastica
parodontale. Trattamento estetico delle
recessioni gengivali.
→ 1st ed. Viterbo (Italy): ACME;
c2010. Chapter #6, Tecniche chirurgiche:
lembo posizionato coronalmente senza
incisioni di rilascio per recessioni multiple;
p. 194–243. Italian.
13.
Ozcelik O, Haytac MC, Seydaoglu G.
Treatment of multiple gingival recessions
using a coronally advanced flap procedure
combined with button application.
→ J Clin Periodontol.
2011 Jun;38(6):572–80.
14.
Zucchelli G, De Sanctis M. Long-term
outcome following treatment of multiple
Miller class I and II recession defects
in esthetic areas of the mouth.
→ J Periodontol.
2005 Dec;76(12):2286–92.

11.
Aroca S, Molnár B, Windisch P, Gera I,
Salvi GE, Nikolidakis D, Sculean A.
Treatment of multiple adjacent miller class
I and II gingival recessions with a Modified
Coronally Advanced Tunnel (MCAT)
technique and a collagen matrix or palatal
connective tissue graft: a randomized,
controlled clinical trial.
→ J Clin Periodontol.
2013 Jul;40(7):713–20.

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Esthetic evaluation of implants after orthodontic space opening treatment

Five-year esthetic evaluation
of implants used to restore
congenitally missing maxillary
lateral incisors after
orthodontic space opening
treatment
Abstract
Objective
Alessandro Mangano,* Alberto Caprioglio,* Francesco
Mangano,* Aldo Macchi,* Luca Levrini* & Carlo Mangano†
Department of Surgical and Morphological Sciences,
University of Insubria, Varese, Italy
†
Department of Stomatology and Biotechnologies,
“Gabriele d’Annunzio” University of Chieti–Pescara,
Chieti, Italy
*

Corresponding author:
Dr. Alessandro Mangano
Clinica Odontostomatologica
Via Giuseppe Piatti, 10
21100 Velate VA
Italy
T
F

This is a five-year follow-up study of a previous investigation with the
aim of assessing the esthetic outcome of Morse taper implants used to
replace congenitally missing lateral incisors after orthodontic treatment.
Materials and methods

Twenty consecutively treated patients were treated using Morse taper
connection implants (Leone Implant System, Leone, Florence, Italy)
after orthodontic space opening. The pink esthetic score/white esthetic score index was applied by an independent calibrated examiner to the
implant-supported restorations at the five-year recall visit, comparing
the esthetic outcome to the previous examinations performed at the
three-month and the three-year recall visits.

+39 033282 5644
+39 033282 5640

Results

ale.mangano10@gmail.com
How to cite this article:
Mangano A, Caprioglio A, Mangano F, Macchi A, Levrini L,
Mangano C. Five-year esthetic evaluation of implants used
to restore congenitally missing maxillary lateral incisors
after orthodontic space opening treatment.
J Oral Science Rehabilitation.
2016 Mar;2(1):62–71.

No implants were lost. All of the implants fulfilled the established success criteria for dental implants with regard to osseointegration and
prosthetic complications, with an overall implant–crown success rate
of 100%. At the five-year follow-up, the mean distance between the
implant shoulder and the first visible bone–implant contact was
0.44 ± 0.14 mm (95% CI: 0.41–0.47), the mean pink esthetic score
was 8.35 ± 1.63 and the mean white esthetic score was 8.80 ± 1.00.
Conclusion

The use of single-tooth Morse taper connection implants for replacing
congenitally missing maxillary lateral incisors after orthodontic treatment appears to be a successful procedure.
Keywords

Implants, congenitally missing lateral incisors, orthodontic space opening treatment.

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Esthetic evaluation of implants after orthodontic space opening treatment

Introduction
Dental agenesis is defined as the congenital absence of a tooth bud. It is a condition of unknown
etiology, although some theories have been formulated.1 Its incidence varies among races and
sexes. Maxillary lateral incisors are the second
most frequent tooth type, after the second premolars and excluding the third molars, affected
by this condition.2 The estimated rate of incidence
of congenitally missing maxillary lateral incisors
ranges from 5% to 8%.3 Dental agenesis occurring in the esthetic area has a high impact on
smile attractiveness, impairing the smile balance
and harmony.4 Therefore, it must be carefully
addressed and requires a team approach.
Classically, congenitally missing lateral incisors can be restored in three ways.5 A camou
flage treatment modality can be performed by
mesialization of the canine into the lateral incisor
space and performing conservative reshaping of
the canine to mimic the incisor.6 A second treatment possibility is a space opening orthodontic
approach, aiming to create adequate space for
the placement of an osseointegrated implant in
the incisal area or to allow the seating of a fixed
partial denture.5 The third option is orthodontic
creation of space in the posterior area to allow
the placement of an implant in the premolar area.7
Implant therapy is an established treatment
modality for the rehabilitation of single or multiple missing teeth with high implant success rates
in the long term.8 Dental implants are able to
provide a high esthetic outcome in very demand
ing clinical situations, such as the rehabilitation
of missing teeth in the premaxilla.9 In the last few
years, investigators have focused their efforts on
determining a reliable method that is able to
evaluate the esthetic outcome of an implantsupported restoration objectively.10 In the late
1990s, Jemt introduced the papilla fill index for
assessing the size of the interproximal gingiva.11
Recently, Fürhauser et al. proposed an index
called the pink esthetic score (PES) that evaluates different aspects of the soft tissue surrounding the implants.12 Unfortunately, this method
focuses only on the outcome of the periimplant
tissue and does not consider the restoration. The
final esthetic result of implant rehabilitation is
the sum of many variables, including the soft
tissue, and the restoration plays a pivotal role in
the final result.13 In 2009, Belser et al. introduced
the pink esthetic score/white esthetic score

(PES/WES), an index able to provide a comprehensive evaluation of the esthetic outcome of an
implant-supported rehabilitation.14 This index
allows the clinician to assess either soft-tissue
variables or variables related to the restoration
itself. A value of 2, 1 or 0 is assigned to every
parameter. An evaluation of all of the variables is
performed by direct comparison with the natural
contralateral reference tooth. Thus, a final score
is assigned that estimates the final degree of
match or mismatch.14
The aim of the present retrospective study is
to evaluate the five-year esthetic outcome of a
single crown supported by a Morse taper connection implant used to replace a congenitally missing maxillary lateral incisor after orthodontic
treatment.
Materials & methods
Patient population

Twenty patients, 11 females and 9 males, with a
mean age of 21.33 (range of 19.67–24.17) were
identified from the patient chart and included in
the study. They had been consecutively treated
with Morse taper connection implants owing to
congenitally missing maxillary lateral incisors
after orthodontic space opening, from 2004 to
2009 at the dental clinic of the University of Insubria (Varese, Italy). Seven patients originally
identified did not meet the inclusion criteria and
were excluded.
The inclusion criteria were
–	presence of natural teeth mesial and distal to
the implant
– presence of the contralateral lateral incisor
–	adequate bone height and width to place an
implant of at least 3.3 mm in diameter and
10.0 mm in length.
The exclusion criteria were
– uncontrolled diabetes
– poor oral hygiene
– active periodontal infections
– bruxism
– smoking habit
– presence of a thin-scalloped gingival biotype.
The biotype was determined by the transparency
of a periodontal probe through the gingival mar-

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Fig. 1

A lateral incisor
at the baseline.

Fig. 2

The implant-supported
restoration after five years.

gin while probing the buccal sulcus of the maxillary central incisor.15 Patients who had undergone implant treatment with hard- or soft-tissue
grafting before implant placement and periodontally compromised patients were excluded too.
All of the patients read and signed a written consent form for immediate implant placement. The
study protocol was conducted in accordance with
the Declaration of Helsinki of 1975, as revised in
2007. The local ethics committee approved the
study protocol.
Surgical and prosthetic procedure

A complete examination of the oral hard and soft
tissue was carried out for each patient, and the
implant placement was planned based on clinical and radiographic evaluation. Surgery was
performed under local anesthesia, obtained by
infiltrating 4% articaine containing 1:100,000
epinephrine (Ubistesin, 3M ESPE, St. Paul, Minn.,
U.S.). A mesiodistal crestal incision was made
and a full-thickness flap was reflected, exposing

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the alveolar ridge. Preparation of implant sites
was carried out with spiral drills of increasing
diameter (2.8 mm to place an implant with a
3.3 mm diameter; 2.8 and 3.5 mm to place an
implant with a 4.1 mm diameter; an additional
4.2 mm drill was used to prepare the site for an
implant with a 4.8 mm diameter), under constant irrigation. Implants were positioned at the
bone crest level. The implant system used in this
study (Leone Implant System, Leone, Florence,
Italy) is characterized by a cone Morse taperedinterference fit locking taper combined with an
internal hexagon. The Morse taper has a taper
angle of 1.5°.
Temporary abutments were placed and all of
the patients received a temporary acrylic resin
crown cemented with a temporary cement
(TempBond, Kerr, Orange, Calif., U.S.). None of
the temporary crowns were in full contact in
centric occlusion. The flaps were properly mobilized and repositioned to cover the implants
and were secured in position with interrupted
sutures (Supramid,Novaxa, Milan, Italy).

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Fig. 3

Figs. 3 & 4

Radiographic control of
the implant at the baseline.
Fig. 4
Radiographic control of
the implant after five years.

All of the patients received oral antibiotics (Augmentin, GlaxoSmithKline, Brentford, UK; 2 g per
day) for six days. Postoperative pain was controlled by administering 100 mg nimesulide
(Aulin, Roche Pharmaceuticals, Basel, Switzerland) every 12 h for two days, and detailed instructions on oral hygiene were given, including
mouth rinsing with 0.12% chlorhexidine (Chlorhexidine, Oral-B, Boston, Mass., U.S.) for seven
days. Suture removal was performed at eight to
ten days. The temporary restorations remained
in situ for three months, and after this period definitive restorations were placed (Figs. 1–3). All
of the single crowns were metal–ceramic and
were cemented with a temporary cement (TempBond).
Clinical follow-up examination

Follow-up visits were scheduled at two weeks,
as well as one, three and 12 months, during the
first year postoperatively and at 24, 36 and 60
months postoperatively. Five years after implant

placement, the following clinical and radiographic parameters were assessed at the recall visit:
(a) presence/absence of pain or suppuration;
(b) presence/absence of clinically detectable implant mobility; (c) presence/absence of prosthetic complications at the implant–abutment interface; (d) presence/absence of periimplant
radiolucency; and (e) distance between the implant shoulder and the first visible bone–implant
contact (DIB). Periapical radiographs were taken
at the baseline (immediately after implant placement) and at the yearly scheduled follow-up
session.16 Radiographs were taken using a Rinn
alignment system (DENTSPLY RINN, Elgin, Ill.,
U.S.) with a rigid film–object X-ray source coupled to a beam-aiming device to achieve reproducible exposure geometry. Customized positioners made of polyvinyl siloxane were used for
precise repositioning and stabilization of the
radiographic template.
In order to calculate the DIB, changes in the
crestal bone level were recorded as changes in
the vertical dimension of the bone around the

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Table 1
Detailed PES values for all 20
restorations at the baseline.

Mesial papilla

Distal papilla

Curvature of
facial mucosa

Level of facial
mucosa

1
2

1
2

2
2

2
2

2
2

2
2

9
10

3

1

2

2

2

2

9

4

2

1

1

1

1

6

5

1

1

2

2

1

7

6

1

1

1

1

1

5

7

2

1

1

2

2

8

8

2

2

1

2

2

9

9

2

2

1

2

2

9

10

2

2

2

2

2

10

11

2

2

1

2

1

8

12

2

2

2

2

1

9

13

2

2

1

1

2

8

14

2

1

1

1

1

6

15

1

2

1

2

1

7

16

1

2

2

1

2

8

17

2

2

2

2

2

10

18

2

1

2

1

1

7

19

1

1

2

2

2

8

20
Mean

1
1.60

2
1.65

2
1.55

1
1.65

1
1.55

7
8.00

Patient

Table 2
Detailed PES values for all 20
restorations at the three-year
follow-up.

Root convexity;
soft-tissue
Total PES
color and
texture

Root convexity;
soft-tissue
Total PES
color and
texture

Mesial papilla

Distal papilla

Curvature of
facial mucosa

Level of facial
mucosa

1
2

2
2

2
2

2
2

2
2

2
2

10
10

3

1

2

2

2

2

9

4

2

2

1

1

1

7

5

1

1

2

2

1

7

6

1

1

1

1

0

4

7

2

1

1

2

2

8

8

2

2

1

2

2

9

9

2

2

2

2

2

10

10

2

2

2

2

2

10

11

2

2

1

2

1

8

12

2

2

2

2

1

9

13

2

2

1

2

2

9

14

2

1

1

1

1

6

15

1

2

1

2

1

7

16

1

2

2

1

2

8

17

2

2

2

2

2

10

18

2

1

2

1

1

7

19

1

1

2

2

2

8

20
Mean

1
1.65

2
1.70

2
1.60

1
1.70

0
1.45

6
8.15

Patient

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Table 3

Mesial papilla

Distal papilla

Curvature of
facial mucosa

Level of facial
mucosa

Root convexity;
soft-tissue
color and
texture

1
2

2
2

2
2

2
2

2
2

2
2

10
10

3

2

2

2

2

2

10

4

2

2

1

1

1

7

5

2

1

2

2

1

8

6

1

1

1

1

0

4

7

2

2

1

2

2

9

8

2

2

1

2

2

9

9

2

2

2

2

2

10

10

2

2

2

2

2

10

11

2

2

1

2

1

8

12

2

2

2

2

1

9

13

2

2

1

2

2

9

14

2

2

1

1

1

7

15

1

2

1

2

1

7

16

2

2

2

1

2

9

17

2

2

2

2

2

10

18

2

1

2

1

1

7

19

1

1

2

2

2

8

20
Mean

1
1.80

2
1.80

2
1.60

1
1.70

0
1.45

6
8.35

Patient

Total PES

Detailed PES values for all 20
restorations at the five-year
follow-up.

Table 4
Patient

Tooth
form

Tooth
volume

Tooth
color

Surface
texture

Translucency

Total WES

1

2

2

2

1

1

8

2

2

2

2

2

1

9

3

2

2

2

1

1

8

4

2

1

1

2

2

8

5

1

2

2

2

2

9

6

1

2

2

2

2

9

7

1

2

2

2

2

9

8

2

2

1

2

1

8

9

2

1

2

2

2

9

10

2

2

2

2

2

10

11

2

1

1

1

1

6

12

1

2

1

2

1

7

13

1

2

2

1

2

8

14

2

2

2

2

2

10

15

2

1

2

2

1

8

16

2

1

1

2

2

8

17

1

1

1

2

2

7

18

2

1

1

2

1

7

19

2

2

1

1

0

6

20

2

2

2

2

2

10

Mean

1.70

1.65

1.60

1.75

1.50

8.15

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Detailed WES values for all 20
restorations at the baseline.

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Table 5
Detailed WES values for all 20
restorations at the three-year
follow-up.

Patient

Tooth
form

Tooth
volume

Tooth
color

Surface
texture

Translucency

Total WES

1

2

2

2

1

2

9

2

2

2

1

2

2

9

3

2

1

2

1

1

7

4

2

1

1

2

2

8

5

1

2

2

2

2

9

6

1

2

2

2

2

9

7

1

2

2

2

1

8

8

2

2

2

2

2

10

9

2

1

2

2

2

9

10

2

2

2

2

1

9

11

2

2

2

2

2

10

12

1

2

1

2

1

7

13

2

2

1

2

2

9

14

2

2

2

2

2

10

15

2

1

2

2

1

8

16

2

1

1

2

2

8

17

2

1

2

2

2

9

18

2

2

1

2

1

8

19

2

2

2

1

1

8

20

2

2

2

2

2

10

Mean

1.80

1.70

1.70

1.85

1.65

8.70

Translucency

Total WES

Table 6
Detailed WES values for
all 20 restorations at the
five-year follow-up.

Patient

Tooth
form

Tooth
volume

Tooth
color

Surface
texture

1
2

2
2

2
2

2
2

1
2

2
2

9
10

3

2

1

2

1

1

7

4

2

1

1

2

2

8

5

1

2

2

2

2

9

6

2

2

2

2

2

10

7

1

2

2

2

1

8

8

2

2

2

2

2

10

9

2

1

2

2

2

9

10

2

2

2

2

1

9

11

2

2

2

2

2

10

12

1

2

1

2

1

7

13

2

2

1

2

2

9

14

2

2

2

2

2

10

15

2

1

2

2

1

8

16

2

1

1

2

2

8

17

2

1

2

2

2

9

18

2

2

1

2

1

8

19

2

2

2

1

1

8

20
Mean

2
1.85

2
1.70

2
1.75

2
1.85

2
1.65

10
8.80

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implant, so that an evaluation of periimplant
crestal bone stability was gained with time. In
order to correct for dimensional distortion in the
radiograph, the apparent dimension of each implant (directly measured on the radiograph) was
compared with the true implant length, in order
to establish with adequate precision the eventual amount of vertical bone loss at the mesial and
distal sites of the implant. The DIB was calculated
by means of an ocular grid. The established criteria for implant–crown success were as follows:
(a) absence of pain or suppuration;(b) absence of
clinically detectable implant mobility; (c) absence of periimplant radiolucency; (d) a DIB of
< 1.5 mm after 12 months of functional loading
and of ≤ 0.2 mm for each following year;17 and
(e) absence of prosthetic complications at the
implant–abutment interface.

part of the treating team, by means of the PES/
WES index 1 h after seating of the definitive
restoration (three months after implant placement), and three years and five years after implant placement (follow-up), respectively.18 In
order to reduce bias and to achieve good reproducibility, the evaluation was carried out twice,
on different days. In the case of diverging scores,
the observer carefully re-evaluated the photographs and the study casts prior to making his
final decision. A score of 2, 1 or 0 was assigned
to each PES/WES parameter. The highest possible PES score was 10, which represented a close match of the periimplant soft-tissue conditions, and the highest possible WES score was
10, representing a close match of the clinical
single-tooth crown compared with the respective features of the natural contralateral tooth.

Esthetic follow-up examination

Data analysis

In order to examine the esthetic outcome of the
implants objectively, intra-oral photographs were
critically analyzed using the PES/WES index.14 All
of the implant crowns were photographed with
a digital camera (Nikon D100, Nikon, Tokyo, Japan) and a 105 mm lens (AF Micro Nikkor 105 mm
1:2.8 D, Nikon) with a ring flash (Nikon SB-29S
Macro Speedlight, Nikon). For assessing anterior
tooth replacements, the reference contralateral
tooth had to be completely and symmetrically
represented in order to ensure comparability. For
this purpose, the photographs were centered at
the midline, in order to facilitate the subsequent
analysis, which was primarily based on symmetry. In addition, standardized clinical photographs
were taken of each implant site and of the contralateral tooth (Figs. 2–4). These additional
photographs were used as tools for a more detailed evaluation. All of the photographs were
taken slightly superior to the occlusal plane, centered at the contact region. Photographs were
then viewed on a 42 in. monitor (PPM42S3Q
Plasma Display Panel Monitor, Samsung, Seoul,
South Korea). Study casts, produced in Type IV
stone, were finally fabricated for each of the 20
patients involved in the study. Study casts were
fabricated to facilitate a direct and objective assessment related to the PES/WES index.
The clinical photographs and the study casts
were used to perform the esthetic evaluation.
The esthetic evaluation was performed by an
independent calibrated observer who was not

For the PES and WES evaluation, descriptive statistics, including mean values, standard deviations,medians and range, were analyzed. Moreover, in order to compare the differences in PES
and WES assessments between the baseline and
follow-up, the Wilcoxon rank-sum test for paired
data was performed. The level of significance was
set at 0.05. All statistical analyses were run on
the SPSS statistical package (Version 17.0; SPSS,
Chicago, Ill.,U.S.).
Results
Data from 20 patients were examined, with a
mean time from surgery to evaluation of five
years. No implants were lost. With regard to osseointegration, all 20 anterior maxillary single-tooth implants fulfilled the success criteria,
with an implant–crown success rate of 100%.
All of the implants showed stable osseointegration, with absence of pain or suppuration, absence of clinically detectable implant mobility,
absence of periimplant radiolucency, a DIB of
< 1.5 mm during the first year of function, and
absence of prosthetic complications at the implant–abutment interface. The mean DIB was
0.44 ± 0.14 mm (95% CI:0.41–0.47) at the fiveyear follow-up.
The five-year PES/WES values are shown in
Tables 1–6. The mean PES was 8.35 ± 1.63. With
respect to the PES index, there was a significant

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improvement compared with the baseline and
the three-year follow-up (p < 0.05). Six implants
scored a perfect PES value at the five-year
evaluation,eight of the remainder had a PES of
≥ 8 and only one implant showed an overall PES
of< 6. The mean WES was 8.8 ± 1.0. With respect
to the WES index, there were no significant differences compared with the baseline and the
three-year follow-up (p < 0.05).
Discussion
Implant therapy is a successful procedure in many
clinical scenarios and nowadays is a reliable and
predictable treatment modality. A number of scientific trials have proved that implants have a high
survival rate in the long term.8, 19, 20 Many investigators have focused on the esthetic outcome of
implants in the esthetic area using different loading protocols, but the literature is scarce on objective evaluation of the esthetic results of implants
used to rehabilitate congenitally missing lateral
incisors.21
The survival rates of implants used to restore maxillary lateral incisors are very high, thus offering
both the clinician and the patient high reliability in
terms of clinical success.13, 22 Our data demonstrated a 100% implant–crown success rate,showing
no implant failure. Furthermore, a stable bone
level was observed throughout the observation
period. This is a crucial aspect for maintaining
long-term function and for achieving an excellent
esthetic outcome. Morse taper connection implants have been proved to yield high functional
performance owing to the implant–abutment
connection stability. When a prosthetic abutment
is connected to a fixture, a microgap is created
between the components. Microorganisms may
grow into this microgap and establish a bacterial
reservoir, resulting in an area of inflamed soft tissue facing the implant–abutment interface. The
presence of this microgap may thus have a role in
the development of periimplant inflammation and
bone loss, as demonstrated by previous studies.23, 24 Our data demonstrated a high PES value
of 8.35 ± 1.63, showing significant differences
compared with the baseline and the three-year
follow-up. Moreover, there were no changes to
the mesial and the distal papillae, and the level of
the facial mucosa remained stable, showing no
recession. For an optimal esthetic result, it is mandatory to preserve the level of the marginal bone
around the implant.21 The main factors hypothe-

76 Volume 2 | Issue 1/2016

sized to be responsible for marginal bone loss include surgical trauma, micromovements of the
abutment, the formation of biologic width, and the
presence and size of a microgap between the implant and the abutment. It is known that when an
abutment is connected to an implant bone loss
always occurs.25 The features of the implant–abutment connection are considered to influence both
the mechanics and the biological behavior of implants.26 The presence of a microgap at the implant–abutment connection may have a direct
effect on bone loss.27 In implants with screw-retained abutments, this microgap can vary in dimension from 40 µm to 100 µm and can be potentially colonized by bacteria, thus generating a
chemotactic stimulus sustaining the recruitment
of inflammatory cells, and ultimately resulting in
inflammation and osteolysis.27
The Morse taper connection is able to avoid
micromovements, removing de facto one of the
reasons for crestal bone resorption. This connection system gives all the advantages of a platform
switching design,achieving a horizontal reposition
ing of the microgap and more space for the establishment of connective tissue; both of these
factors play an important role in the maintenance
of a biological seal against bacteria that can impair
the marginal bone stability.28 With regard to the
WES index, no differences were observed in the
present study. After five years of function, the
mean DIB was 0.44 ± 0.14 mm, demonstrating
that this particular kind of implant connection
system is able to guarantee bone stability in
the long term, as demonstrated by previous
studies.16, 29
Conclusion
Within the limits of this study, the use of
single-tooth Morse taper connection implants
for the restoration of congenitally missing maxillary lateral incisors after orthodontic treatment
appears to be a successful procedure, demonstrating (a) a high PES value, (b) a high esthetic
outcome in the long-term and (c) a high implant–
crown success rate.
Competing interests
The authors declare that they have no competing
interests related to this study. No financial support was received for this study.

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Guidelines for authors

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Title

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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, conclusion, and keywords.
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

78 Volume 2 | Issue 1/2016

Journal of
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[79] => U1_Cover_A4_ePaper.qxp_Layout 1

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
www.ncbi.nlm.nih.gov/books/NBK7256/
should be presented succinctly (in English). The auThe reference list may not exceed 50 references.
thor bears full responsibility for the content. Color,
animated multimedia presentations, videos and so
on are welcome and published at no additional cost
List of captions
to the author or reader. Please refer briefly to such
Please provide the captions for all visual material at material in the manuscript where appropriate (e.g.,
as an endnote).
the end of the manuscript.
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
Dr. Daniele Botticelli at
daniele.botticelli@gmail.com

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 2 | Issue 1/2016

79

[80] => U1_Cover_A4_ePaper.qxp_Layout 1

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

International office
Dental Tribune International
Holbeinstr. 29
04229 Leipzig
Germany
T +49 341 4847 4302
F +49 341 4847 4173
info@dental-tribune.com
www.dental-tribune.com

Nathalie Schüller
n.schueller@dental-tribune.com

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

Concept & design

Associate editors

Rhowerk
www.rhowerk.com

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

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, Rome, 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 the duplication of 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

80 Volume 2 | Issue 1/2016

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

[81] => U1_Cover_A4_ePaper.qxp_Layout 1

€50/issue of the Journal
(4 issues/year; including
VAT and shipping costs,
for a total of €200/year)
Your subscription will be
renewed automatically
every year until a written
cancellation is sent
six weeks prior to the
renewal date to
Dental Tribune
International GmbH,
Holbeinstr. 29, 04229
Leipzig, Germany.

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© MIS Corporation. All rights Reserved.

GLOBAL
CONFERENCE 2016

May 26-29, Barcelona

BARCELONA DREAM TEAM
MAKE IT SIMPLE
MIS is proud to introduce the Global Conference Speakers Team: Alexander Declerck • Anas Aloum
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• Federico Hernández Alfaro • Florian Schober • France Lambert • Gabi Chaushu • Galip Gürel
• Giulio Rasperini • Guillermo J. Pradíes Ramiro• Gustavo Giordani • Hilal Kuday • Ignacio Sanz Martin
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• Marco Esposito • Mariano Sanz Alonzo • Miguel Troiano • Mirela Feraru-Bichacho • Mithridade
Davarpanah • Moshe Goldstein • Nardi Casap • Nelson Carranza • Nitzan Bichacho • Nuno Sousa Dias
• Pablo Galindo-Moreno • Stavros Pelekanos • Stefen Koubi • Tommie Van de Velde • Victor Clavijo
• Vincent Fehmer • Yuval Jacoby. To learn more about the conference visit: www.mis-implants.com/barcelona

®

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[cover] => Journal of Oral Science & Rehabilitation No. 1, 2016

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Table of contents

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