Journal of Oral Science & Rehabilitation No. 2, 2018

Journal of Oral Science & Rehabilitation No. 2, 2018

Cover / Editorial / Content / About the Journal of Oral Science & Rehabilitation / Guided bone regeneration around 1-stage nonsubmerged dental implants with periimplant bone defects: A retrospective case series study / Extraoral chairside digitalization: Clinical reports on a new digital protocol for surgical and prosthetic treatment of completely edentulous patients / Digital face-bow transfer technique using the dentofacial analyzer for dental esthetics and 2-D, 3-D smile design: A clinical report / Low implant insertion torque allows minimal bone loss: A multicenter 2-year prospective study / Implant-supported mandibular complete fixed prosthesis with conometric retention after 3 years of functional loading / Evaluation of the incidence and prevalence of temporomandibular joint dysfunction in psychiatric patients using typical antipsychotic drugs / Industry News / Guidelines for authors / Imprint

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Journal of

Oral Science
&
Rehabilitation
I S S N 2 3 6 5 - 6 8 9 1 (Online)

Volume 4 — Issue 2/2018

I S S N 2 3 6 5 - 6 1 2 3 (Print)

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

[2] => JOSR_2_2018_web.pdf

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[3] => JOSR_2_2018_web.pdf

Editorial

Journal of

Oral Science
&
Rehabilitation
Surface treatment of ceramics

In modern prosthodontic dentistry, metal-free ceramics are widely used materials, and knowledge
of their unique cementation procedures is paramount for a modern dentist. In order to achieve
optimal adhesion between teeth and ceramics, knowing the composition and properties of adhesives
is not enough. It is important to know how dental tissue and the different ceramics interact with
them, and how these substrates can be treated beforehand in order to achieve optimal results.
As technology has progressed, different types of ceramics have been introduced, such as feldspathic
porcelain, leucite-reinforced ceramics, lithium disilicate and zirconia. These materials have similar
esthetic properties, but different mechanical and chemical properties. The difference in properties
between ceramics is directly related to their structural differences: The presence or absence of
leucite crystals, the radically different shape of lithium disilicate crystals and zirconium oxide
particles, and other features of ceramics directly inﬂuence the type of surface treatment needed to
obtain an optimal chemical adhesion. Each material needs to be treated in a certain way before
cementation, and knowing this could yield overall better clinical results.
Nowadays, sandblasting glass-ceramic surfaces (feldspathic, leucite and lithium disilicate) is not
advised, because this kind of treatment could ﬂatten them and create microfractures in the glossy
matrix, leading to future failure of the restoration. A tribochemical treatment on zirconia using
aluminum oxide particles, however, is advised; it increases surface roughness and augments chemical adhesion owing to the particles embedded in the zirconia’s surface.
The gold standard for treating glass-ceramic surfaces is etching; however, for different ceramics,
different etching times must be applied:
– For feldspathic ceramics, etching with 5% hydroﬂuoric acid for 120 s is advised.
– For leucite-reinforced ceramics, etching with 5% hydroﬂuoric acid for 60 s is advised.
– For lithium disilicate, etching with 5% hydroﬂuoric acid for 20 s is advised.
For zirconia, etching is not advised, as it has been demonstrated that its surface is rendered chemically
inert by this treatment.
In conclusion, clinicians should feel compelled to research and study this subject in order to combine
their knowledge of adhesive materials with the knowledge of chemical characteristics and best
surface treatments for both the dental substrate and the restoration substrate.

Dr. Giacomo Derchi
Board of reviewers
Dr. Vincenzo Marchio

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 2/2018 03

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Content

3
Editorial
Dr. Giacomo Derchi
6
About the Journal of Oral Science & Rehabilitation
8
Amparo Aloy Prósper et al.
Guided bone regeneration around 1-stage nonsubmerged dental implants
with periimplant bone defects: A retrospective case series study
16
Marco Tallarico et al.
Extraoral chairside digitalization: Clinical reports on a new digital protocol
for surgical and prosthetic treatment of completely edentulous patients
22
Christian Brenes et al.
Digital face-bow transfer technique using the dentofacial analyzer
for dental esthetics and 2-D, 3-D smile design: A clinical report
32
Yi Man et al.
Low implant insertion torque allows minimal bone loss: A multicenter
2-year prospective study
40
Eriberto Bressan et al.
Implant-supported mandibular complete ﬁxed prosthesis with
conometric retention after 3 years of functional loading
46
Elizabeth Maria Costa de Carvalho et al.
Evaluation of the incidence and prevalence of temporomandibular joint
dysfunction in psychiatric patients using typical antipsychotic drugs
54
Industry news
56
Guidelines for authors
58
Imprint— about the publisher

04 Volume 4 | Issue 2/2018

Journal of
Oral Science & Rehabilitation

[5] => JOSR_2_2018_web.pdf

[6] => JOSR_2_2018_web.pdf

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 4 | Issue 2/2018

Journal of
Oral Science & Rehabilitation

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About

Benefits
of publishing in the journal for authors
There are numerous advantages of publishing in the Journal of Oral
Science & Rehabilitation:
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means without prior permission in writing from the copyright holder.

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 2/2018 07

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GBR with a nonsubmerged approach

Guided bone regeneration around
1-stage nonsubmerged dental implants
with periimplant bone defects:
A retrospective case series study
Abstract
Objective
Amparo Aloy Prósper,a David Peñarrocha Oltra,a
Hilario Pellicer Chóver,a Maria Peñarrocha Diagoa
& Miguel Peñarrocha Diagoa
a

Stomatology Department, Faculty of Medicine and
Dentistry, University of Valencia, Valencia, Spain

Corresponding author:
Dr. Amparo Aloy Prósper
Clínicas odontológicas
Gascó Oliag, 1
46021 Valencia
Spain
amparo.aloyprosper@gmail.com
T +34 963 864 139
How to cite this article:
Aloy Prósper A, Peñarrocha Oltra D, Pellicer Chóver H,
Peñarrocha Diago M, Peñarrocha Diago M. Guided bone
regeneration around 1-stage nonsubmerged dental
implants with periimplant bone defects: A retrospective
case series study.
J Oral Science Rehabilitation. 2018 Jun;4(2):08–14.

The aim was to evaluate the 3-year outcome of nonsubmerged dental
implants with buccal periimplant defects treated with a guided bone
regeneration technique in a 1-stage approach.
Method and materials

A retrospective chart review of consecutive patients treated with dental
implants and bone regeneration at the time of implant placement, left
nonsubmerged, and with a minimum follow-up of 3 years after implant
loading was performed. Patients were treated between January 2005
and December 2009 at the Oral Surgery Unit of the University of Valencia, Valencia, Spain. The following variables were assessed: complications
with the healing procedure, implant success (based on Buser et al.22),
and periimplant marginal bone loss. Statistical analysis was performed
applying Chi2 test, Spearman's test and the Mann-Whitney test, using
alpha set at 0.05.
Results

A total of 50 patients (26 women, 24 men) with a mean age of
54.8 ± 13.6 years (range: 25–79) and 75 implants were included. Seventyone dehiscences (average height: 1.97 ± 1.06 mm) and 4 fenestrations
(average height: 2.75 ± 0.95 mm) were treated. Five membrane exposures
were recorded (10%). After 3 years post-loading, the implant success
rate was 94% and mean marginal bone loss was 0.50 ± 0.27 mm.
Conclusion

Despite the limitations of this study, a nonsubmerged approach in connection with guided bone regeneration to treat periimplant bone defects
is a feasible option with few healing complications and a good prognosis.
Keywords

Guided bone regeneration; periimplant defects; dental implants; marginal
bone loss; success rate; nonsubmerged.

08 Volume 4 | Issue 2/2018

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GBR with a nonsubmerged approach

Introduction
The application of guided bone regeneration
(GBR) provides clinicians with the ability to
place implants in areas of insufficient amounts
of bone.1 The 1-stage approach, using grafting
material with or without membranes at the
time of implant placement, has the advantage
of shortening the total treatment time. 2 GBR
utilizing a 1 -stage procedure around submerged implants has been widely documented
in humans1, 3, 4 and animals. 5–7 Several experimental studies in animals on nonsubmerged
immediate implants placed in extraction sockets with GBR indicated that bone regeneration
around these implants was possible; 8–10 and
clinical studies on humans conﬁrmed these
results with good long-term outcomes.11, 12
Defects from fresh extraction sockets are
characterized by the maintenance of intact
surrounding bone walls, which offer favorable
conditions for regenerative processes. However, when dental implants are placed in
narrow ridges, the lack of 1 or more walls leads
to open defects, which are less favorable for
the regenerative process, since the blood clot
is less protected, grafted bone particles are
more subject to displacement, and a membrane placed to cover the defect may collapse.13 Despite the 1-stage approach having
the advantage of shortening the total treatment time, different syste matic reviews on
clinical outcomes of GBR procedures to correct
periimplant dehiscences and fenestrations
show that in most of the included studies
dental implants were left submerged. There
are few studies on GBR around nonsubmerged
implants for treating periimplant bone defects
in narrow alveolar ridges.14–19 The purpose of
the present study was to evaluate the 3-year
outcome of 1 -stage nonsubmerged dental
implants with buccal periimplant defects
treated with a GBR technique and resorbable
membranes.

simultaneous particulate bone grafting with
resorbable membranes and left nonsubmerged.
Patients were treated between January 2005
and December 2009 at the Oral Surgery Unit of
the University of Valencia, Valencia, Spain, and
were monitored annually for a minimum of 3
years post-loading. The study was performed
following the guidelines of the Declaration of
Helsinki for human research. Surgical procedures were performed by the same surgeon with
extensive experience in regenerative procedures. Patients were given full information
about the surgical procedures and duly signed
informed consent forms. Preoperative analysis
included registering complete medical histories
and performing clinical and radiographic examinations.
Subject and site inclusion criteria:
– Dental implant with a dehiscence or fenestration bony defect during implant placement
treated with particulate bone graft and resorbable membranes.
– Nonsubmerged dental implants.
– Tooth/teeth at implant site extracted > 6
months previously.
– Rehabilitation with a fixed or removable
implant-supported prosthesis.
– Age > 18 years.
– No relevant medical conditions.
– Nonsmoking or smoking ≤ 20 cigarettes/day
(all pipe or cigar smokers were excluded).
– Follow-up for at least three years after prosthetic loading.

Subject and site exclusion criteria:
– Patients with systemic or local conditions contraindicating implant therapy (previous
chemotherapy, previous irradiation of the head
and neck region, active progressive periodontitis and/or immunosuppression).
– Pregnant or lactating patients.
– Sites with acute infection.
– Poor oral hygiene.
– Implants with sinus augmentation.
– Immediate implants or placed in bone with a
Materials and methods
recent extraction (< 6 months).
– Reimplantation.
Patient selection
– Implants placed in bone previously regenerated with bone grafting.
A retrospective clinical study was conducted of – Patients failing to attend follow-up visits.
patients with a minimum of 1 dental implant
demonstrating a dehiscence or fenestration The present study is reported in accordance with
bony defect with an exposed implant surface the Strengthening the Reporting of Observational
during implant placement and thus undergoing Studies in Epidemiology statement.20
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GBR with a nonsubmerged approach

Figs. 1A–C

C
Figs. 1D–F

Fig. 1
Patient with dehiscences
treated with GBR with a
nonsubmerged approach.
(A) Preoperative panoramic
radiograph.
(B) Preoperative occlusal view.
(C) Bone atrophy of the
alveolar ridge visualized after
ﬂap elevation.
(D) Implant insertion in
positions #35, 36 and 37.
(E) Synthetic bone over
dehiscences.
(F) Resorbable membrane over
bone graft.

Preoperative evaluation

Thorough medical histories, clinical examinations and panoramic radiographs were
performed in all cases. Cone-beam computed
tomographic scans were obtained to assess the
availability of bone whenever the surgeon considered this necessary. Periodontal treatment
was provided whenever necessary to control
inﬂammation prior to implant placement surgery. Within 10 days of the implant placement
surgery, a full-mouth professional prophylaxis
appointment was scheduled.
Surgical procedures

All procedures were performed under local anesthesia using 4% articaine with 1:100,000
epinephrine (Inibsa, Lliçà de Vall, Spain) and intravenous conscious sedation with a 1% propofol
solution, administered by an anesthesiologist.
An initial incision was made slightly palatal/
lingual of the alveolar crest. One or 2 releasing
incisions were made and a mucoperiosteal ﬂap
was raised. The exposed alveolar bone was
curetted to remove all soft tissue. In order to
enhance primary stability, drills and osteotomes
were combined to prepare implant beds. TSA
implants with the Avantblast surface (Phibo
Dental Solutions, Sentmenat, Spain) were
10 Volume 4 | Issue 2/2018

inserted using standard procedures following
the manufacturer’s guidelines. These implants
had a polished surface portion of 1.5 mm. All
implants were placed with adequate primary
stability (≥ 35 N cm). All implants were treated
by guided bone regeneration with autologous
bone grafts harvested from the conformation
of implant beds during drilling and adjusted to
the bone contour, or a mix with synthetic bone
of 0.25–1 mm of particle (Kera–Os, Keramat,
Coruña, Spain) when the autologous bone
obtained was insufficient to cover the periimplant defects. Grafted bone was protected with
a textured collagen membrane (Lyopstic,
B-Braun, Aesculap, Tuttlingen, Germany).
Periosteal incisions were made to allow flap
mobilization and tension-free primary wound
closure. Afterward, the mucoperiosteal ﬂap was
resutured, leaving the implant head exposed to
the oral cavity (Fig. 1). No provisional restorations
were loaded on the implants. Patients were prescribed 1 g of amoxicillin (GlaxoSmithKline,
Madrid, Spain) twice daily for 6 days, starting 1 h
prior to surgery,21 600 mg of ibuprofen (Bexistar,
Laboratorio Bacino, Barcelona, Spain) 3 times per
day for 5 days and a mouthrinse containing 0.12%
chlorhexidine (GUM, John O. Butler/Sunstar,
Chicago, Ill., U.S.) twice daily, commencing 3 days
prior to surgery and for 2 weeks thereafter.
Patients were instructed in adequate hygiene

Journal of
Oral Science & Rehabilitation

[11] => JOSR_2_2018_web.pdf

GBR with a nonsubmerged approach

Figs. 1G–J

G

H

I

J

Figs. 1K & L

K

L

maintenance. Patients were not allowed to use
removable prostheses for 3 weeks after bone
grafting surgeries. A soft diet was recommended
for 1 week, and patients were instructed to avoid
brushing or any other trauma to the surgical sites.
Sutures were removed 2 weeks after surgery.
Data collection and follow-up

All data collection was carried out by a single
trained clinician different from the surgeon or
the prosthodontist following a pre-established
protocol. All patients were included in a maintenance program involving annual examinations
and professional prophylaxis. Occlusal adjustment was performed when necessary.
Patient age (at implant placement), sex,
hygiene and smoking habits (none/< 10 cigarettes per day/10–20 cigarettes per day) were
registered. For each implant, the position, and
the type and dimensions of defects (dehiscence/
fenestration) were registered. Defects were
measured using a millimetric periodontal probe
(UNC, Hu-Friedy, Chicago, Ill., U.S.) placed
parallel or perpendicular to the long axis of the
implant. Measurements were recorded to the
nearest 1 mm mark. The type of graft was
recorded (autologous bone or mixed). The deﬁnitive prosthesis design (single or partial) and type
of prosthesis (cemented or screwed) were

recorded. The following outcome measures
were recorded:
Receptor site healing: Membrane exposure.
Implant success: The definition of implant
success was based on the clinical and radiographic criteria put forward by Buser et al.22. The
implant success rate was provided per patient.
Radiographic periimplant marginal bone loss:
Intraoral radiographs were taken at the moment
of prosthetic loading (baseline), 1 year postloading and 3 years post-loading (control radiographs), using the X-Mind intraoral system
(Satelec-Pierre Rolland Group, Merignac,
France) and an RVG intraoral digital receptor
(Dürr Dental, Bietigheim-Bissingen, Germany)
with the aid of a Rinn XCP ﬁlm holder (Dentsply
Rinn, Elgin, Ill., U.S.) to achieve parallelism. The
images were calibrated with CliniView
(Version 5.1, Instrumentarium Imaging, Tuusula,
Finland). Each image was calibrated using the
known length of the implants. The vertical distance from the outer edge of the implant shoulder (reference point) to the most coronal point
of bone-to-implant contact was evaluated at
the mesial and distal aspects of each implant
to the nearest 0.1 mm. Periimplant marginal
bone resorption at 3 years post-loading was
calculated from the change in bone level
between the 1-year post-loading and the 3-year
control radiographs; for each pair of

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 2/2018 11

Fig. 1
(G) Sutures.
(H) Healed soft tissue.
(I) Occlusal view of prosthesis
placement.
(J) Lateral view of prosthesis
placement.
(K) One-year post-loading
panoramic radiograph.
(L) Three-year post-loading
panoramic radiograph.

[12] => JOSR_2_2018_web.pdf

GBR with a nonsubmerged approach

measurements (mesial and distal), the largest
value was used. Intraexaminer calibration was
analyzed before evaluating the entire implant
sample by reassessing bone loss at a total of 30
randomly selected sites (using the random function of Microsoft Excel 2010) on duplicate
measurements performed on different days. An
intraclass correlation coefficient of 0.898 was
obtained, showing a high concordance between
the 2 sets of data. According to Dahlberg’s
d value, a 0.049 mm error was estimated for
the measurement method.
Statistical analysis

Statistical analysis was performed using nonparametric tests for implant success, as this was
a noncontinuous variable, and marginal bone
loss, as this had an asymmetric distribution. The
chi-square test was used to study the relationship between the survival and success rates with
respect to sex, smoking and hygiene habits,
position and location of the implants, type
defect, type of graft, prosthesis design and
membrane exposure. Spearman's test was used
to relate the mean of bone loss and age and mean
periimplant defect dimensions; and the
Mann-Whitney test to relate this variable with
type of graft and exposure membrane. Statistical analysis was performed using SPSS software (Version 17.0, SPSS, Chicago, Ill., U.S.).

Results
A total of 66 patients with GBR around nonsubmerged dental implants performed owing
to the presence of dehiscences and fenestrations were included. Sixteen patients were
excluded as a result of failing to attend control
visits. The ﬁnal study sample was 50 patients
( 26 women, 24 men) with a mean age of
54.8 ± 13.6 years (range: 25–79). Hygiene maintenance was good in 39 patients and regular
in 11. Thirty-eight patients were nonsmokers,
9 smoked < 10 cigarettes per day and 3 between
10 and 20 cigarettes.
A total of 75 dental implants were placed:
28 maxillary (9 anterior, 19 posterior) and
47 mandibular ( 10 anterior, 37 posterior).
Seventy-seven defects around 75 implants were
produced (73 dehiscences, 4 fenestrations). The
mean dimensions of the resulting dehiscence
defects were 1.97 ± 1.06 mm (range: 1.5–8.0) in
height and 3.29 mm (range: 3.0–5.5) in width.
12 Volume 4 | Issue 2/2018

The mean dimensions of the resulting fenestration defects were 2 .75 ± 0. 95 mm (range:
2.0–4.0) in height and 2.1 mm (range: 1.5–3.0)
in width. Regarding the type of graft, 12 implants
received autologous bone and 63 a mix with
synthetic bone. With regard to prosthetic rehabilitation, 21 implants had single crowns and
54 fixed bridges, and 28 prostheses were
cemented and 47 screwed.
Receptor site healing

Wound dehiscence with membrane exposure
during the early postoperative period occurred
in 5 grafted sites in 5 patients. These exposures
did not exceed 3 mm in diameter. In these cases,
0.2% chlorhexidine gel was prescribed for application 3 times daily to the exposed membrane
for 6 weeks after surgery. All sites re-epithelialized
uneventfully.
Implant success rate,
and periimplant
marginal bone loss

Three implants in 3 patients were lost, all of
them before loading, between 1 and 3 months.
All 3 implants had periimplant bone dehiscences
of 2 mm in width and length. Two patients were
men with an average age of 40–63 years and 1 a
woman of 46 years. All these patients maintained regular oral hygiene. One was a nonsmoker and 2 were smokers. All failed implants
had been placed in posterior sites (2 mandibular
and 1 maxillary) and did not exceed 10.0 mm in
length and 4.2 mm in width.
Implant success rate per patient was 94%
after 1 year post-loading. Mean periimplant marginal bone loss at 1 year post-loading was
0.42 ± 0. 31 mm (range: 0.1–1 .9). At 3 years
post-loading, no further implants had been lost
and were considered successful according to
Buser et al.’s criteria.22 Mean periimplant marginal bone loss at 3 years post-loading was
0.50 ± 0.27 mm (range: 0.2–1.8).
No significant differences were found
between success rate and bone loss regarding
patient factors (age, sex and smoking habit) or
implant variables (location, type defect, defect
dimensions, type of graft, prostheses design or
membrane exposure). However, all implant failures occurred in patients with regular oral
hygiene ( 100 %); these results showed a
moderate tendency to signiﬁcance, but were
nevertheless nonsigniﬁcant (P value: 0.073).

Journal of
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GBR with a nonsubmerged approach

Discussion
This study was designed to evaluate, after a
minimum of 3 years of prosthetic loading, the
survival and success rates of nonsubmerged
implants with periimplant bone defects treated
with particulate bone grafts and resorbable
membranes in a 1-stage approach. The results
of this study show that a nonsubmerged
approach is a feasible option when periimplant
bone defects are produced during implant surgery owing to anatomical reasons.
The outcomes of the present study are comparable with those of studies on submerged
implants.1, 4, 23, 24 In a recent systematic review,
Chiapasco and Zaniboni reported that the overall survival rate of implants with periimplant
defects treated with GBR, irrespective of the
timing of the implants, the type of membrane
and grafting materials, was 95 .7 % (range:
84.7–100) within the observation period, varying
from 1 to 9 years. 25 In only 1 out of 7 studies
included in the review had nonsubmerged
implants been placed.14 De Boever and De Boever
studied long-term outcomes of nonsubmerged
implants placed with a xenograft and a nonresorbable membrane to cover large dehiscences in a 1-stage approach and reported a
93.75% survival rate and stable marginal bone
loss after a 5-year follow-up.14 Nonresorbable
membranes are still regarded as the gold standard in GBR; however, frequently reported
soft-tissue problems, such as exposure of the
membrane and subsequent infection, as well as
the need to remove the membrane, have led to
the development and use of resorbable membranes.26, 27 The use of bioresorbable membranes
almost always requires autologous bone or
deproteinized bovine bone mineral as a scaffold
for the membrane. 9 In the present study, all
defects were treated with autologous bone graft
alone, or in combination with synthetic bone,
and a resorbable membrane.
Regarding receptor site healing, Blanco et al.
studied 26 implants with periimplant defects
treated with nonresorbable membranes combined with autogenous bone grafts or decalciﬁed freeze-dried bone allograft and reported
11.5% membrane exposure that required premature removal.23 In the present study, membrane
exposure occurred in 10 % of grafting sites.
These results agree with those of Juodzbalys et
al., who reported a 5% resorbable membrane
exposure rate.17 The periapical radiographs of
the sites showed no continuous periimplant

radiolucency at the 3-year follow-up examination. The mean marginal bone loss after 3 years
was 0.50 ± 0.27 mm. The results of this study
are in agreement with those reported by
De Boever and De Boever on GBR around nonsubmerged implants; these authors reported no
marginal periimplant bone resorption except for
1 implant after 12–114 months of follow-up.18
Nevins et al., in a retrospective multicenter
study, reported a mean radiographic bone loss,
over a 74-month period post-loading, of 0.64 mm
(range: 0. 3– 0.8).16 These results agree with
those reported on a submerged implant
approach; Ramel et al. reported a mean bone
loss of 0.43 ± 0.56 mm 1 year post-loading and
a further bone loss of 0.17 mm in the following
2 years.27 Juodzbalys et al. reported that 90%
of all sites presented with stable crestal bone
levels.17 Christensen et al. found that 14% of the
sites treated with GBR showed 1.5 mm of bone
loss 3 years post-loading.15
The results of the study seem to show that
bone regenerated with GBR around nonsubmerged dental implants remains stable over
time with a good prognosis for the implants;
however, some limitations should be noted. The
ﬁrst limitation is that the study did not include
a control group and re-entries were not performed, so it provides no evidence of the effectiveness regarding bone regeneration, and the
effectiveness of this technique was thus based
on the postoperative complications and dental
implant survival and success rates. The second
limitation of the study is the absence of a radiographic outcome that could measure the amount
of regenerated bone, because using a one-stage
approach does not make it possible to measure
it directly.28 Finally, the third limitation is the
retrospective nature of this research.

Conclusion
Despite the limitations of this study, nonsubmerged implant placement in connection with
GBR to treat periimplant bone defects is a
feasible option with few healing complications
and good long-term prognosis. Further longterm studies with appropriate controls and
larger sample sizes and longer follow-ups should
be conducted in order to conﬁrm or reject these
ﬁndings.

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GBR with a nonsubmerged approach

References
1.
Benić GI, Jung RE, Siegenthaler DW,
Hämmerle CH. Clinical and radiographic
comparison of implants in regenerated
or native bone: 5-year results.
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2009 May;20(5):507–13.

8.
Brunel G, Benqué E, Elharar F, Sansac C,
Duffort JF, Barthet P, Baysse E, Miller N.
Guided bone regeneration for immediate
non-submerged implant placement using
bioabsorbable materials in Beagle dogs.
→ Clin Oral Implants Res.
1998 Oct;9(5):303–12.

2.
Hämmerle CH, Jung RE. Bone
augmentation by means of barrier
membranes.
→ Periodontology 2000.
2003 Oct;33:36–53.
3.
Lorenzoni M, Pertl C, Polansky RA, Jakse
N, Wegscheider WA. Evaluation of
implants placed with barrier membranes.
A retrospective follow-up study up to
ﬁve years.
→ Clin Oral Implants Res.
2002 Jun;13(3):274–80.
4.
Zitzmann NU, Schärer P, Marinello CP.
Long-term results of implants treated
with guided bone regeneration: a 5-year
prospective study.
→ Int J Oral Maxillofac Implants.
2001 May–Jun;16(3):355–66.

9.
Kohal RJ, Trejo PM, Wirsching C,
Hürzeler MB, Caffesse RG. Comparison
of bioabsorbable and bioinert
membranes for guided bone regeneration
around non-submerged implants. An
experimental study in the mongrel dog.
→ Clin Oral Implants Res.
1999 Jun;10(3):226–37.
10.
Fiorellini JP, Engebretson SP, Donath K,
Weber HP. Guided bone regeneration
utilizing expanded polytetraﬂuoroethylene membranes in combination with
submerged and nonsubmerged dental
implants in beagle dogs.
→ J Periodontol.
1998 May;69(5):528–35.
11.
Siciliano VI, Salvi GE, Matarasso S,
Caﬁero C, Blasi A, Lang NP. Soft tissues
healing at immediate transmucosal
implants placed into molar extraction
sites with buccal self-contained
dehiscences. A 12-month controlled
clinical trial.
→ Clin Oral Implants Res.
2009 May;20(5):482–8.

5.
Hämmerle CH, Brägger U, Schmid B,
Lang NP. Successful bone formation
at immediate transmucosal implants:
a clinical report.
→ Int J Oral Maxillofac Implants.
1998 Jul–Aug;13(4):522–30.
6.
Hürzeler MB, Kohal RJ, Naghshbandi J,
Mota LF, Conradt J, Hutmacher D,
Caffesse RG. Evaluation of a new
bioresorbable barrier to facilitate guided
bone regeneration around exposed
implant threads. An experimental study
in the monkey.
→ Int J Oral Maxillofac Surg.
1998 Aug;27(4):315–20.
7.
Carmagnola D, Berglundh T, Araújo M,
Albrektsson T, Lindhe J. Bone healing
around implants placed in a jaw defect
augmented with Bio-Oss. An experimental study in dogs.
→ J Clin Periodontol.
2000 Nov;27(11):799–805.

12.
Cordaro L, Torsello F, Roccuzzo M.
Clinical outcome of submerged vs.
non-submerged implants placed in fresh
extraction sockets.
→ Clin Oral Implants Res.
2009 Dec;20(12):1307–13.
13.
Vanden Bogaerde L. A proposal for the
classiﬁcation of bony defects adjacent
to dental implants.
→ Int J Periodontics Restorative Dent.
2004 Jun;24(3):264–71.

15.
Christensen DK, Karoussis IK, Joss A,
Hämmerle CH, Lang NP. Simultaneous
or staged installation with guided bone
augmentation of transmucosal titanium
implants. A 3-year prospective cohort
study.
→ Clin Oral Implants Res.
2003 Dec;14(6):680–6.
16.
Nevins M, Mellonig JT, Clem DS 3rd,
Reiser GM, Buser DA. Implants in
regenerated bone: long-term survival.
→ Int J Periodontics Restorative Dent.
1998 Feb;18(1):34–45.
17.
Juodzbalys G, Raustia AM, Kubilius R. A
5-year follow-up study on one-stage
implants inserted concomitantly with
localized alveolar ridge augmentation.
→ J Oral Rehabil.
2007 Oct;34(10):781–9.
18.
De Boever AL, De Boever JA. A one-stage
approach for nonsubmerged implants
using a xenograft in narrow ridges:
a report of seven cases.
→ Int J Periodontics Restorative Dent.
2003 Apr;23(2):169–75.
19.
Cochran DL, Douglas HB. Augmentation
of osseous tissue around nonsubmerged
endosseous dental implants.
→ Int J Periodontics Restorative Dent.
1993 Dec;13(6):506–19.
20.
Kuller LH, Goldstein BD. Suggestions
for STROBE recommendations.
→ Epidemiology.
2007 Nov;18(6):792–3.
21.
Esposito M, Grusovin MG, Loli V,
Coulthard P, Worthington HV. Does
antibiotic prophylaxis at implant
placement decrease early implant
failures? A Cochrane systematic review.
→ Eur J Oral Implantol.
2010 Summer;3(2):101–10.

14.
De Boever AL, De Boever JA. Guided
bone regeneration around non-submerged
implants in narrow alveolar ridges:
a prospective long-term clinical study.
→ Clin Oral Implants Res.
2005 Oct;16(5):549–56.

14 Volume 4 | Issue 2/2018

Journal of
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22.
Buser D, Mericske-Stern R, Dula K, Lang
NP. Clinical experience with one-stage,
non-submerged dental implants.
→ Adv Dent Res.
1999 Jun;13:153–61.
23.
Blanco J, Alonso A, Sanz M. Long-term
results and survival rate of implants
treated with guided bone regeneration:
a 5-year case series prospective study.
→ Clin Oral Implants Res.
2005 Jun;16(3):294–301.
24.
Hämmerle CH, Jung RE, Feloutzis A. A
systematic review of the survival of
implants in bone sites augmented with
barrier membranes (guided bone
regeneration) in partially edentulous
patients.
→ J Clin Periodontol.
2002;29 Suppl 3:226–31; discussion
232–3.
25.
Chiapasco M, Zaniboni M. Clinical
outcomes of GBR procedures to correct
peri-implant dehiscences and
fenestrations: a systematic review.
→ Clin Oral Implants Res.
2009 Sep;20 Suppl 4:113–23.
26.
Urban IA, Nagursky H, Lozada JL.
Horizontal ridge augmentation with a
resorbable membrane and particulated
autogenous bone with or without
anorganic bovine bone-derived mineral:
a prospective case series in 22 patients.
→ Int J Oral Maxillofac Implants.
2011 Mar–Apr;26(2):404–14.
27.
Ramel CF, Wismeijer DA, Hämmerle CH,
Jung RE. A randomized, controlled
clinical evaluation of a synthetic gel
membrane for guided bone regeneration
around dental implants: clinical and
radiologic 1- and 3-year results.
→ Int J Oral Maxillofac Implants.
2012 Mar–Apr;27(2):435–41.
28.
Meloni SM, Jovanovic SA, Urban I,
Canullo L, Pisano M, Tallarico M.
Horizontal Ridge augmentation using
GBR with a native collagen membrane
and 1:1 ratio of particulated xenograft
and autologous bone: a 1-year
prospective clinical study.
→ Clin Implant Dent Relat Res.
2017 Feb;19(1):38–45.

[15] => JOSR_2_2018_web.pdf

BUENOS AIRES 2018

Buenos Aires

World Dental Congress

Argentina

5-8 September 2018
A PASSION

IT
M
M
O
FOR MANY, A C

FO
T
MEN

.  WProgramme
now online
www.world-dental-congress.org

LL
A
R

[16] => JOSR_2_2018_web.pdf

Extraoral chairside digitalization

Extraoral chairside digitalization:
Clinical reports on a new digital protocol
for surgical and prosthetic treatment of
completely edentulous patients
Abstract

Aim
Marco Tallarico,a Erta Xhanari,b Matteo Martinolli,c
Edoardo Baldonid & Silvio Mario Melonie
a

Aldent University, Tirana, Albania; private practice,
Rome, Italy
b
Aldent University, Tirana, Albania; private practice, Tirana
c
Private practice, Porto Viro, Italy
d
University of Sassari, Sassari, Italy
e
University of Sassari, Sassari, Italy; private practice,
Sassari

Corresponding author:
Dr. Marco Tallarico
Via di Val Tellina 116
00151 Rome
Italy
How to cite this article:
Tallarico M, Xhanari E, Martinolli M, Baldoni E, Meloni
SM. Extraoral chairside digitalization: Clinical reports on
a new digital protocol for surgical and prosthetic
treatment of completely edentulous patients.
J Oral Science Rehabilitation. 2018 Jun;4(2):16–20.

Nowadays, virtual planning and the assisted placement of implants in
3-D positions relative to the bone, soft tissue and ﬁnal planned prosthesis
are becoming the gold standard. In order to obtain such visualization, it
is necessary to correctly match the anatomical and prosthetic data. The
aim of this paper is to present a new extraoral chairside prosthesis scanning protocol for fully edentulous patients.
Materials and methods

This study was designed as a pilot case series study aimed at evaluating
the feasibility of a new extraoral chairside prosthesis scanning protocol
for guided implant surgery in completely edentulous arches. This new
protocol includes 2 extraoral chairside scans using a powdered intraoral
scanner. The ﬁrst part is based on the extraoral chairside digitalization
of the current prosthesis with added radiopaque markers made in
flowable composite and subsequent imaging superimposition with
DICOM data. The second part is based on the extraoral chairside digitalization of conventional scan abutments ﬁxed on a specially designed
customized tray, based on the original virtual planning.
Results

Three patients (1 man and 2 women) with a mean age of 58.9 years were
treated. A total of 13 implants were placed using a guided approach. All
of the patients underwent 2 extraoral chairside digitalizations with no
deviation from the original protocol. No implant failed and the prosthetic
survival rate was 100 %.
Conclusion

Within the limits of this study, it is suggested that extraoral chairside
digitalization may provide better accuracy than conventional methods,
permitting fast, easy and accurate treatment at a decreased cost.
Randomized controlled trials are needed to evaluate predictability and
repeatability of this workﬂow.
Keywords

Guided surgery; dental implants; intraoral scanner.
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Extraoral chairside digitalization

Introduction

article is to present this new extraoral chairside
prosthesis scanning protocol for fully edentuAdvancements in computerized tomography lous patients.
scanning (cone beam computed tomography
[CBCT] technologies), coupled with computerassisted treatment, have allowed for the virtual
Materials and methods
planning and assisted placement of implants in
3-D positions relative to the bone, soft tissue This study was designed as a pilot case series
and final planned prosthesis.1 –5 In order to study aimed at evaluating the feasibility of a new
obtain such visualization, it is necessary to protocol for guided implant surgery of comcorrectly match the anatomical and prosthetic pletely edentulous arches that includes 2 extradata. The prosthetic information can be oral chairside scans using a powdered intraoral
acquired in different ways, and it depends on scanner (True Definition Scanner, 3M Italia,
whether the patient is edentulous or still has Pioltello, Italy). Three patients ( 1 man and
remaining teeth. With edentulous patients, it 2 women) with a mean age of 58.9 years were
is possible to create a scan prosthesis by con- treated. Basically, patients with an adequate
verting a functionally and esthetically correct pre-existing or a newly developed removable
prosthesis into a scan prosthesis by placing complete dental prosthesis in at least one jaw
radiopaque markers such as gutta-percha and requiring an implant-supported rehabilitahemispheres (double-scan protocol). 6 The tion were considered eligible for this pilot study
double-scan protocol is based on 2 separate and consecutively treated in a private center in
sets of DICOM ﬁles. It can be used for both Rome, Italy. The study was conducted in accorpartially and completely edentulous patients. dance with the principles outlined in the
The ﬁrst CBCT scan is of the patient wearing Declaration of Helsinki of 1964 for biomedical
the radiographic guide with the radiopaque research involving human subjects, as amended
markers. The second scan is of the patient’s in 2008. The patients were duly informed about
radiographic guide alone. Converting raw data the nature of the study. Written informed
to 3-D information is done by various software consent to surgical treatment was obtained from
available or by sending the data to the master each patient.
site of the particular software manufacturers.
Noticeable drawbacks of the original double- E x t r a o r a l c h a i r s i d e d i g i t a l i z a t i o n
scan technique are the need for 2 CBCT scans
of the current prosthesis
and the associated costs, as well as the
technique- sensitive nature of the process. The patient’s medical history was collected,
Furthermore, extraoral chairside digitalization preoperative photographs and radiographs were
allows for easy handling of the controlling obtained, and periodontal screening was perfactors for the accuracy of impression tech- formed for initial evaluation. During the clinical
niques, compared with intraoral scanning.
examination, the existing removable complete
In order to overcome these disadvantages, a dental prosthesis was evaluated for function and
new digital protocol has been introduced to the esthetics. Then, the ﬁt was carefully assessed,
profession for the treatment of fully edentulous rebasing the existing prosthesis directly chairside
patients. This newly developed protocol involves if needed (Fig. 1). The prosthetically driven plan2 parts. The ﬁrst part (planning) is based on ning workﬂow started by adding 6–8 drops of
extraoral chairside digitalization of the current ﬂowable composite to the existing prosthesis
prosthesis with added radiopaque markers made (Fig. 2). Then, the patient underwent a CBCT scan
in ﬂowable composite and subsequent imaging (CRANEX 3Dx, SOREDEX, Tuusula, Finland)
superimposition with the DICOM data.7 The wearing the modiﬁed dental prosthesis. A wax
advantage of this new technique is that the bite was used to separate the dental arches
surgical template obtained is derived from the (Fig. 3). The second scan was for the extraoral
intraoral scan that is more precise than the one chairside digitalization of the prosthesis with
obtained from CBCT. The second part (ﬁnaliza- added radiopaque markers (True Definition
tion) is based on the extraoral chairside digitali- Scanner). In accordance with the manufacturer’s
zation of conventional scan abutments ﬁxed on instructions, the entire area to be scanned was
a specially designed customized tray, based on powdered just before scanning (Fig. 4). The STL
the original virtual planning. The purpose of this and DICOM data were imported into a
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Extraoral chairside digitalization

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 1
Pre-existing complete
removable denture during
intraoral rebasing.
Fig. 2
Pre-existing complete
removable denture with
6–8 drops of radiopaque
ﬂowable composite.
Fig. 3
Pre-existing complete
removable denture in
the patient’s mouth during
CBCT scanning.
Fig. 4
Powdered pre-existing
complete removable denture
before extraoral digitalization.
Fig. 5
Matching of the digitalized
pre-existing prosthesis with
the CBCT scan.

Fig. 5

3-D software planning program (3Diagnosys, on the approved prosthetic setup (Figs. 7 & 8).
Version 5.0, 3DIEMME, Cantù, Italy). The repro- In accordance with the manufacturer’s instruc-

cessed surface extrapolated from the DICOM
data and the surface of the existing prosthesis
generated by the scanning process were merged
with the best-ﬁt repositioning tools of the software using the composite radiopaque markers
(Fig. 5). Implants (Osstem TSIII, Osstem, Seoul,
South Korea) were planned according to the prosthetic setup. After careful functional and esthetic
evaluation and ﬁnal veriﬁcation, the prosthetically driven plans were approved, and stereolithographic surgical templates were fabricated
with a newer rapid prototyping technology
(LightSolutions, New Ancorvis, Bargellino, Italy).
One hour before implant placement, patients
underwent professional oral hygiene and
received prophylactic antibiotic therapy (2 g of
amoxicillin or 600 mg of clindamycin if allergic
to penicillin). A total of 13 implants were placed
using a guided approach according to previously
published protocols.
Extraoral chairside digitalization
of the final implant positions

After osseointegration, extraoral chairside digitalization of the ﬁnal implant positions was
performed using dedicated scan abutments
(Type AQ, New Ancorvis; Fig. 6) ﬁxed intraorally
on a specially designed customized tray based
18 Volume 4 | Issue 2/2018

tions, before scanning (True Deﬁnition Scanner),
the entire area to be scanned was powdered
lightly (Fig. 9). The customized tray was designed
maintaining the tooth design, but allowing the
screwing on of the scan abutments. The obtained
STL ﬁles were matched with the previous planning containing all the information about esthetics and function, including occlusal vertical
dimension and bite registration in centric relation (Fig. 10).
Definitive restorations were delivered
according to the individual treatment plans. Up
to 1 year after deﬁnitive prosthesis delivery, no
implant had failed and the prosthetic survival
rate was 100 %.

Discussion
Nowadays, guided surgery is aimed at preparing
the implant case and placing implants in the
correct prosthetically guided positions. Implantsupported overdentures are an accepted and
predictable treatment modality for patients with
edentulous jaws. 5 Clinical studies have documented high survival rates for observation
periods of up to 10 years, a high level of patient
satisfaction and an improved quality of life compared with conventional dentures.8–10

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Extraoral chairside digitalization

Fig. 6

Fig. 7

Fig. 6
Scan abutments screwed on
to the implants.
Fig. 7
Specially designed customized
tray positioned in the patient’s
mouth.

Fig. 8

Fig. 8
Scan abutments ﬁxed to the
customized tray.

Fig. 9

Fig. 9
Powdered customized tray
before extraoral digitalization.
Fig. 10
Matching of the digitalized
customized tray and the
ﬁnal implant positions with
the original plan.
Fig. 10

However, it should not be forgotten that the
improvement of intraoral scanning techniques
and technologies can allow us to make the most
of the digital workﬂow for the ﬁnalization of
the case and consequently to reduce the
number of appointments and costs for the
patient. Another advantage is the signiﬁcant
reduction in laboratory time and complexity
when compared with more conventional
approaches that involve fabrication of the bar
patterns with acrylic resin, investment, and
casting of dental alloys.11 Additionally, because
the casting step is eliminated, problems associated with the cost of the alloy, control of the

investment expansion, and shrinkage of the
alloy are also eliminated.12–14
After a careful literature review and correctly analyzing the latest technological developments of intraoral scanners, it was decided
to modify the double-scan technique proposed
by Van Steenberghe et al. that provided for
2 CBCT scans. 6 In the proposed technique, the
second scan results in the extraoral digitalization of the radiographic guide with added 3-D
radiopaque markers. The advantage of this new
technique is that the surgical template obtained
is derived from the intraoral scan that is more
precise than the one obtained from CBCT.

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Extraoral chairside digitalization

Presently, after implant osseointegration, the best
way to finalize the case is to take a definitive
impression of the implants and to use the temporary prosthesis, if present and functionally and
esthetically suitable, to articulate the opposite
arch cast to incorporate into the articulator functional information on the provisional (function,
vertical dimension, centric relation, esthetics).
With the new proposed impression tray, which is
derived from the prosthetic setup used for the
guided surgery, then already approved by the
clinician and the patient, we transfer to the dental
technician, with a single appointment, the ﬁnal
implant positions, the centric relation, the vertical
dimension, and the esthetic and functional parameters. The limits of this technique are the management of soft tissue, which may require a second
scan of the tissue with the scan abutments, always
in the same session. The advantage is also that

the scan of this new modiﬁed tray can be done
outside the patient’s mouth, reducing the discomfort for the patient and increasing the accuracy.

Conclusion
Extraoral chairside digitalization may provide
better accuracy than conventional methods,
permitting fast, easy and accurate treatments
at a decreased cost. Randomized controlled
trials are needed to evaluate predictability and
repeatability of this workﬂow.

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

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20 Volume 4 | Issue 2/2018

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maxillary overdentures after a mean
observation period of at least 1 year.
→ J Clin Periodontol.
2010 Jan;37(1):98–110.
9.
Cehreli MC, Karasoy D, Kökat AM, Akça
K, Eckert S. A systematic review of
marginal bone loss around implants
retaining or supporting overdentures.
→ Int J Oral Maxillofac Implants.
2010 Mar–Apr;25(2):266–77.
10.
Emami E, Heydecke G, Rompré PH, de
Grandmont P, Feine JS. Impact of implant
support for mandibular dentures on
satisfaction, oral and general healthrelated quality of life: a meta-analysis of
randomized-controlled trials.
→ Clin Oral Implants Res.
2009 Jun;20(6):533–44.
11.
Spyropoulou PE, Razzoog ME, Duff RE,
Chronaios D, Saglik B, Tarrazzi DE.
Maxillary implant-supported bar
overdenture and mandibular implantretained ﬁxed denture using CAD/CAM
technology and 3-D design software:
a clinical report.
→ J Prosthet Dent.
2011 Jun;105(6):356–62.

Journal of
Oral Science & Rehabilitation

12.
Abduo J, Lyons K, Bennani V, Waddell N,
Swain M. Fit of screw-retained ﬁxed
implant frameworks fabricated by
different methods: a systematic review.
→ Int J Prosthodont.
2011 May–Jun;24(3):207–20.
13.
Moeller MS, Duff RE, Razzoog ME.
Rehabilitation of malpositioned implants
with a CAD/CAM milled implant
overdenture: a clinical report.
→ J Prosthet Dent.
2011 Mar;105(3):143–6.
14.
Spyropoulou PE, Razzoog ME, Duff RE,
Chronaios D, Saglik B, Tarrazzi DE.
Maxillary implant-supported bar
overdenture and mandibular implantretained ﬁxed denture using CAD/CAM
technology and 3-D design software:
a clinical report.
→ J Prosthet Dent.
2011 Jun;105(6):356–62.

[21] => JOSR_2_2018_web.pdf

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[22] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Digital face-bow transfer
technique using the dentofacial
analyzer for dental esthetics
and 2-D, 3-D smile design:
A clinical report

Abstract

Christian Brenes,a Larry Jurgutisb & Courtney S. Babba
epartment of General Dentistry, Dental College of
D
Georgia, Augusta University, Augusta, Ga., U.S.
b
Dental College of Georgia, Augusta University, Augusta,
Ga. U.S.

Corresponding author:
Dr. Christian Brenes
Dental College of Georgia
1120 15th St. GC-3224
Augusta, Ga. 30912
U.S.

This article describes an effective and affordable technique for transferring a face-bow relation record to a virtual articulator for the proper
orientation of the maxillary digital model using the Kois Dento-Facial
Analyzer System. In complex esthetic and full-mouth rehabilitation
cases, the orientation of the models to the articulator is crucial for the
evaluation of excursive movements. The article elaborates on the
necessary steps to use the face-bow transfer technique to design esthetic
veneers based on a 2-D, 3-D smile design approach using a clinical case
as an example of the protocol.
Keywords

T +1 706 446 5777
cbrenesvega@augusta.edu

Digital face-bow; digital wax-up; CAD/CAM; smile design; dentofacial
analyzer.

How to cite this article:
Brenes C, Jurgutis L, Babb CS. Digital face-bow transfer
technique using the dentofacial analyzer for dental
esthetics and 2-D, 3-D smile design: A clinical report.
J Oral Science Rehabilitation. 2018 Jun;4(2):22–30.

22 Volume 4 | Issue 2/2018

Journal of
Oral Science & Rehabilitation

[23] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Introduction
Digital workﬂows are becoming more popular
and are in demand among clinicians and laboratory technicians owing to the increased incorporation of CAD/CAM tools into the daily practice. Digitization of records and data through
cone beam computed tomography (CBCT) scans,
intraoral scans and model manipulation contributes to better communication processes for
diagnostics, treatment planning, designing and
manufacturing in dentistry.
In past decades, clinicians and laboratory
technicians have used analog articulators to
simulate hinge and eccentric movements of the
mandible, allowing for the fabrication of waxups and final restorations; the evaluation of
occlusal function is fundamental to any dental
treatment.1, 2 Face-bows were developed as a
complement to different articulator systems to
orient the maxillary arch to the center of rotation
of the condyles in 3 planes of space and transfer
the position to the articulator; similar movements can be reproduced for occlusal evaluation
and diagnosis once the models have been
properly mounted.3, 4
In recent years, the incorporation of CAD/
CAM technology has provided for more efficient
protocols by automating processes and reducing
manual labor. Intraoral scanners can digitize
dental arches and register maxillomandibular
relationships. 5, 6 Currently, many CAD/CAM
systems include a virtual articulator simulatory
module as a tool to simulate mandibular movements, which can be adjusted by using numerical
values to represent condylar inclination, Bennett
angle, vertical dimension, etc. The equivalent of
analog mounted maxillary and mandibular casts
still applies in the digital workﬂow for a proper
evaluation; however, a major challenge has been
to transfer the maxillary arch position without
an analog tool such as a face-bow. A digital
model behaves similarly to a ﬂoating object in
space: The 3 -D models are not accurately
oriented in the x, y and z coordinates when they
are digitally scanned, which makes identifying
the facial midline and occlusal plane impossible
without proper points of reference (Fig. 1). In
complex esthetic and full-mouth rehabilitation
cases, it is crucial to identify the midline and
plane of occlusion to recognize any potential
canting and occlusal problems.7
Panadent introduced a simpliﬁed system for
transferring mounted study casts to the analog
articulator, called the Kois Dento-Facial Analyzer

System, or Dento-Facial Analyzer (DFA). The
Dento-Facial Analyzer system is a device created
by Dr. Kois and sold by Panadent (Panadent,
California); the occlusal stand ﬁts directly onto
the magnetic mount of the Panadent articulator
series; several companies have developed compatible occlusal stands to ﬁt their articulators
and similar systems. The device basically consists of a Fox plane with an adjustable middle
rod (Fig. 2). An index tray is attached to the
device to record the position of the maxillary
arch using bite registration material and to
transfer the patient’s occlusal plane and midline
in the 3 planes of space to the analog articulator
with a magnetic plate that attaches to an occlusal stand (Figs. 3 & 4). This allows mounting of
the casts at a ﬁxed distance of 100 mm, which
is based on Kois’s research on average axis–
incisal distance, which is substantiated by
Bonwill’s equilateral triangle theory and
Monson’s spherical theory.8–10
Different techniques have been proposed to
transfer this information into the CAD software,
but most are more time-consuming and complex, using full-volume CBCT data or 3-D facial
scanners and different software to generate
data able to align the maxillary scan to the
skull.11, 12 Most affordable 3-D facial scanners
(under $ 5,000) do not generate high-quality
meshes that can be used to directly align dental
casts. The scans are able to capture color and
can confuse clinicians about the true quality of
the underlying mesh; without the color, the quality of the underlying mesh is typically distorted
and does not represent the shape of the actual
object (Fig. 5). Moreover, 3-D facial scanners
need to have reference markers to align the
digital dental models to the facial scan, which
makes the process more complicated than using
an analog face-bow.
The technique described in this article overcomes these problems because it can align
digital casts to the virtual articulator by using a
bite scan in conjunction with the DFA. The facebow transfer technique is described as follows:
1. Properly take a dentofacial record using the
Kois DFA, aligning the middle rod to the midline of the patient and capturing the occlusal
plane orientation with the Fox plane. Several
materials, such as polyvinylsiloxane bite
registration material, wax or impression compound, can be used on the plastic index tray.
2. Scan the maxillary and mandibular arches
with an intraoral scanner along with the bite
record. The intraoral scan used in this case

Journal of
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Volume 4 | Issue 2/2018 23

[24] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Fig. 1

Fig. 1
Digital model imported into
exocad dental software; the
red lines illustrate the dental
midline and occlusal plane
estimated from tooth position
without reference points.
Fig. 2
Patient holding the Kois
Dento-Facial Analyzer System;
the middle rod corresponds to
the facial midline and the Fox
plane is parallel to the
interpupillary line.

Fig. 2

Fig. 3

Fig. 4

Fig. 3
Index tray with bite
registration material.
Fig. 4
Occlusal stand with index tray
and dental model mounted.

was PlanScan (Planmeca), Helsinki, Finland),
but any intraoral scan or laboratory scan will
work for its implementation (Figs. 6 & 7).
3. Scan 1 bite record to align maxillary and mandibular arches and scan an additional bite
record using the previous record captured
with the plastic index tray on the maxillary
cast. Since the plastic index tray was used as
a record to capture the midline and plane of
occlusion with the DFA, the external middle
rod and the Fox plane are not needed for the
bite record scan. The anterior middle notch in
the index tray corresponds to the facial midline and the base of the tray corresponds to
the occlusal plane (Fig. 8).
4. Align all models and bite records in the software.
5. Export all STL models and import to the
design software or use it within the CAD software if the digital system has a CAD module
integrated to start designing the anterior restorations or digital wax-up.
6. If the CAD software has an articulator module
available, the bite record can also be used; in
this case, the exocad articulator module was
used (exocad, Darmstadt, Germany). Click the
boxes that display the horizontal and vertical
planes of the articulator. Align the corresponding planes: midline notch of the index
24 Volume 4 | Issue 2/2018

tray to the vertical plane of the articulator;
and base of the index tray to the horizontal
occlusal plane of the articulator (Figs. 9 & 10).
In addition to the basic alignment, the clinician
has 2 different ways to correlate the anterior
posterior distance of the digital model with the
virtual articulator. The ﬁrst option is available
if the clinician already has a full-face skull CBCT
(wide ﬁeld of view, approximately 20 × 18 cm,
standard resolution). The distance from the
center of rotation of the condyles to the central
incisors can be measured and reproduced in
the articulator module (Fig. 11); the exocad
DICOM viewer module can be used to measure
the CBCT data and correlate the dental model
scan of the maxillary arch. The second option
is using the average axis–incisal distance
reported by Kois’s research of 100 –110 mm,
which corresponds to the average anthropometric distance from the center of rotation of
the condyles to the incisal edge of the maxillary
central incisors; that is the distance traditionally used with the Panadent articulator models
PCF and PSH and the occlusal stand used to
mount the plastic index tray. A 3-D measurement ruler tool can be used in most CAD dental
software to establish the distance and thus
position the models.

Journal of
Oral Science & Rehabilitation

[25] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Fig. 5

Fig. 5
3-D facial scan showing the
same mesh with and without
color. The quality of the mesh
without color can be
appreciated and is not a good
representation of the patient
anatomy for registration
purposes.
Fig. 6
Maxillary and mandibular
models aligned in occlusion.
Fig. 7
Maxillary and mandibular
models aligned displaying the
bite record.
Fig. 6

Fig. 7

Fig. 8
Scanned model and index tray
bite record showing the
corresponding facial midline
determined by the middle
notch of the index tray and the
occlusal plane determined by
the base of the index tray.
Fig. 9
Frontal view of the model
orientation based on the
horizontal plane of the virtual
articulator.

Fig. 8

Fig. 9

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 2/2018 25

[26] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Fig. 10

Fig. 11

Fig. 10
Lateral view of the model
orientation based on the
vertical plane of the virtual
articulator.
Fig. 11
Model orientation in the
virtual articulator using the
distance from the center
of rotation of the condyles to
the central incisors as the
distance for proper mounting.
Fig. 12
Preoperative smile
photograph.
Fig. 12

Fig. 13
Preoperative intraoral
photograph.

Fig. 13

Fig. 14
3-D smile design simulation.

Fig. 14

This technique is beneﬁcial in anterior esthetic
cases and helpful in 3-D smile designs. The
advantage of using a 2-D, 3-D integrated CAD
design is that any request from the patient can
be done instantly in the 3-D design, eliminating
the need for a conventional wax-up, which takes
hours, and minimizing the clinical time needed to
obtain a cast, because the cast can be manufactured by means of a 3-D printer or milling machine,
26 Volume 4 | Issue 2/2018

making the protocol extremely efficient. Furthermore, using 2-D images captured by photographic
cameras or high-deﬁnition video cameras and
superimposing them to 3-D data is the quickest
and simplest approach. A 3-D facial scanner often
cannot capture a smile in fractions of a second
like a photograph can; instead, the patient has to
hold the smile for several seconds, making it more
difficult for clinicians to capture a true smile.

Journal of
Oral Science & Rehabilitation

[27] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Georgia, U.S., with the chief complaint of worn
and stained anterior teeth (Figs. 12 & 13). The
patient was a smoker and reportedly smoked a
pack per week. During the ﬁrst appointment,
clinical and radiographic examinations were
done for proper diagnosis and formulation of a
treatment plan. The clinical examination
revealed attrition on the anterior teeth and
maxillary premolars, stable periodontal health
with probing depths of < 3 mm, and no endodontic lesions or pathology. A thorough occlusal
analysis was done, with no signiﬁcant ﬁndings.
Maximum intercuspation position was coincidental with centric relation, and no alteration of
the vertical dimension was diagnosed. After
evaluation of the patient records, a set of intraClinical report
oral and extraoral preoperative photographs was
A 62-year-old woman presented to the Compre- taken, along with a DFA record, which includes
hensive Care Clinic at the Dental College of a record of the midline and occlusal plane based
Georgia at Augusta University, Augusta, on facial esthetics (Fig. 14). Incisal edge position
Another advantage to using a virtual wax-up is
the possibility of using cross-sectional views to
visualize and measure the addition of restorative
material prior to starting an invasive procedure.
This is an extremely useful educational tool for
minimally invasive techniques that can improve
the appearance of the smile and at the same time
offer a better prognosis by preserving tooth
structure.13, 14
The purpose of this article is to describe the
2-D, 3-D smile design integration and its beneﬁts
in the provisionalization stage after using the
digital face-bow transfer technique.

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 2/2018 27

Fig. 15
Virtual articulator.
Fig. 16
Putty jig made on the printed
model for the mock-up.
Fig. 17
Mock-up used as reductions
guide for tooth preparation.
Fig. 18
Intraoral photograph
of conservative veneer
preparations.
Fig. 19
Intraoral photograph
of conservative veneer
preparations.

[28] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Fig. 20

Fig. 21

Fig. 22

Fig. 23

was determined ﬁrst by adding composite to the
left maxillary central incisor as a guide to establish the new length based on the evaluation of
lips at rest and during smiling.15 The composite
restoration is not bonded to tooth structure and
is only used to determine the esthetic incisal
edge position during rest position, phonetics and
smiling. Once the position is stablished the
length is recorded for the future digital wax-up
and the composite is removed. A prophylaxis
was done during the appointment to treat some
of the extrinsic staining present on the teeth.
With the diagnostic information acquired
during the first appointment, the steps of
aligning the models using the face-bow transfer
technique with the DFA system were followed.
A 2-D image of the patient was imported and
aligned using match points to develop a 3-D
functional virtual wax-up by adding restorative
material to the maxillary anterior teeth and ﬁrst
premolars. A natural tooth library with squareshaped teeth similar to the patient’s natural
anatomy was selected to create the virtual diagnostic wax-up to reproduce shape and texture.
The dental software used in this case (exocad)
also has a tooth color selection option to show
a simulation of tooth shade, which facilitates the
patient’s visual perception of the proposed treatment and improves treatment acceptance
(Fig. 14). The design was evaluated functionally
using the articulator module for excursive movements (Fig. 15).
The virtual 3-D smile design was shown to
the patient at the second visit. She was able to
visualize the possible results of the esthetic
treatment and participate by giving feedback
before any invasive procedures were initiated.

No modiﬁcations were requested. The virtual
wax-up was 3-D printed (MoonRay S, SprintRay,
Los Angeles, Calif., U.S.) and a putty jig was
created on the model to generate a mock-up for
the patient using bis-acryl (Integrity, Dentsply
Sirona, York, Pa., U.S.; Fig. 16) owing to its
minimal shrinkage and excellent esthetic results.
The mock-up has 2 functions. The ﬁrst is to serve
as an esthetic and functional prototype that
enables the patient to visualize and experience
the end result with a restorative material. Any
modiﬁcations can be done at this stage because
it is temporary and noninvasive. The second
function is to work as a reduction guide once the
patient has approved it; the reduction is created
through the mock-up material and not through
tooth structure (Fig. 17).
Minimally invasive preparation (0.5–0.8 mm
facial reduction and 1 . 5 mm incisal/occlusal
reduction) was done for the labial esthetic
veneers, allowing for enamel preservation
(Figs. 18 & 19). A ﬁnal impression was taken and
the 3-D virtual design was used as the preoperative digital model, since no modiﬁcations were
done intraorally after verification. Leucite
glass-ceramic blocks (IPS Empress CAD, Ivoclar
Vivadent, Schaan, Liechtenstein) were milled for
the final veneer restorations in-house using
a milling machine (PlanMill 4.0, Planmeca;
Figs. 20 & 21). Final characterization was done
after glazing.
At the delivery appointment, an esthetic
try-in was done prior to bonding the restorations.
The patient approved the esthetics, marginal ﬁt
was veriﬁed, and the teeth and restorations were
etched and bonded (Variolink Esthetic, Ivoclar
Vivadent). The patient was extremely satisﬁed

Fig. 20
Milled IPS Empress CAD
veneer blocks.
Fig. 21
Milled IPS Empress CAD
veneers.
Fig. 22
Bonded veneers, lateral view.
Fig. 23
Bonded veneers, occlusal
view.

28 Volume 4 | Issue 2/2018

Journal of
Oral Science & Rehabilitation

[29] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

Fig. 24

Fig. 25

with the treatment outcome (Figs. 22–25). An
occlusal guard was provided as part of the treatment plan. At the 1-year follow-up, the patient
reported no complications.

Discussion
This article presents a simpliﬁed digital technique for transferring the face-bow information
to the articulator. Transferring the position of
the digital models in relation to the face is
important to reproduce functional movements
and have predictable esthetic results. Previous
techniques using CBCT units require that the
patient be submitted to unnecessary radiation
to orient the models. In addition, other techniques using 3 -D facial scanners require
expensive hardware; most clinicians cannot
justify this expense only for orientation purposes,
and both of these methods require more time
and are more complex in nature.
The face-bow transfer technique could also
be used with edentulous patients by using occlusal
rims as the reference points for the central incisors. The occlusal rim and the bite record with the
plate would have to be scanned in order to register the meshes and align the edentulous models.
However, this could be more technique-sensitive
owing to the lack of stability of the bases.
While other bite forks can be used for the
technique presented here, the authors highly
recommend the DFA because of its ease of use.
This technique is compatible with any virtual
articulator, unlike analog articulators that
require brand-compatible stands. This creates
a universal digital transfer technique that can

be efficiently shared digitally with any other
clinician or laboratory technician. While additional studies are needed to validate accuracy
and reproducibility, this technique has the
potential to greatly improve the workﬂow of
digital dentistry. The process could be made
even more efficient with the implementation of
a direct align algorithm in dental software
upgrades and with the incorporation of jaw
tracking devices and tracking scans. This technique is extremely useful in 3-D smile design
cases or esthetic cases that require the visualization of facial landmarks such as the midline
and plane of occlusion.

Conclusion
The digital face-bow transfer technique using
the DFA system is a predictable, quick and easy
method of scanning and aligning digital models
to a virtual articulator without the need for
expensive equipment.

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

Acknowledgments
The authors would like to thank the following
companies: exocad, Planmeca, SprintRay, and
Roland for the support provided for education
and research; their help was of tremendous value.

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 2/2018 29

Fig. 24
Postoperative frontal smile.
Fig. 25
Postoperative lateral smile.

[30] => JOSR_2_2018_web.pdf

Digital face-bow transfer technique

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[31] => JOSR_2_2018_web.pdf

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[32] => JOSR_2_2018_web.pdf

Low torque leads to minimal bone loss

Low implant insertion torque allows
minimal bone loss: A multicenter 2-year
prospective study

Abstract

Objective
Yi Man,a Xin Xu,b Zuolin Wang,c Ofer Mosesd &
Zhonghao Liue
a

West China Hospital of Stomatology, Sichuan University,
Chengdu, China
b
Stomatology Hospital of Shandong University, Jinan,
China
c
Affiliated Stomatology Hospital of Tongji University,
Shanghai, China
d
School of Dental Medicine, Tel Aviv University, Tel Aviv,
Israel
e
Yantai Stomatological Hospital, Yantai, China

Corresponding author:
Prof. Ofer Moses
School of Dental Medicine
Tel Aviv University
Ramat Aviv 6997801
Tel Aviv
Israel

The aim of this multicenter prospective study was to evaluate the survival
rate of implants after insertion using low torque (< 35 N cm), by recording measurements from resonance frequency analysis (RFA), probing
pocket depths and changes in interproximal crestal bone level.
Materials and methods

This multicenter prospective clinical study was performed in partially
edentulous subjects. The patients treated in the study received 1–4 SPI
implants (Alpha-Bio Tec, Petah Tikva, Israel), which were loaded 4 months
after implantation. Measurements of torque and RFA were recorded
immediately after implant insertion. New RFA measurements were taken
at the time of implant exposure surgery, prior to connection of the healing
abutments. Baseline measurements of bone level were taken both directly
and radiographically immediately after insertion and were compared
with measurements taken during the 2-year follow-up period.

mosesofer@gmail.com

Results

How to cite this article:
Man Y, Xu X, Wang Z, Moses O, Liu Z. Low implant
insertion torque allows minimal bone loss: A multicenter
2-year prospective study.
J Oral Science Rehabilitation. 2018 Jun;4(2):32–38.

Of 88 treated subjects, 83 completed the 2-year follow-up. Of 137
implants, 5 were lost. The survival rate after 2 years of follow-up was
96.5% and the mean marginal bone loss was 0.531 mm. The mean
measurement for RFA at the time of implantation was 74.92 and this
increased to 76.26 prior to insertion of the prostheses.
Conclusion

Within the limits of the study, implants inserted with low torque
(< 35 N cm), displayed high survival rates with high RFA scores and
minimal bone loss at the 2-year mark after implantation.
Keywords

Implants; bone loss; RFA; resonance frequency analysis.
32 Volume 4 | Issue 2/2018

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Introduction
Nowadays, dental implants are widely used as
a treatment for fully and partially edentulous
patients, and the survival rate has been reported
to be high.1, 2 However, certain risk factors may
predispose to an increased risk of implant failure
and a lower success rate. Risk factors for
implant failure can be divided mainly into
2 groups.3 The ﬁrst group of risk factors includes
surgical technique, retention technique, the primary stability of the implant, and variables
affecting the implant prosthesis, such as the
length, diameter and location of the implant.
The second group involves patient-related factors, such as smoking, diabetes, alcohol abuse,
oral hygiene habits and a history of periodontitis. Controversy remains, however, concerning
the linkage between certain risk factors and
dental implant failure. 3–6
Dental implant success may be characterized
by initial and long-term stability of the implant
and healthy periimplant hard and soft tissue.7 It
is widely accepted that marginal bone loss of
approximately 1.0 mm during the ﬁrst year after
prosthetic loading and subsequent annual bone
loss not exceeding 0.2 mm are consistent with
successful treatment. 8, 9
A wide variety of techniques have been used
for measuring implant stability at various clinically relevant reference points in time. The
techniques currently most often used to measure stability are insertion torque, Periotest and
resonance frequency analysis (RFA).10 While
clinically useful, insertion torque is limited to
implant insertion and thus cannot be used to
determine secondary stability. Conversely, RFA
is a noninvasive and widely used method to
quantify implant stability at any stage during
implant treatment and the follow-up period.11, 12
The RFA technique for measuring implant stability was developed by Meredith and coworkers almost 30 years ago and is commercially available as the Osstell device.12 A sensor
(SmartPeg) is mounted on top of the implant
and the sensor is then brought to vibration by
gently moving it with magnetic pulses. The
sensor will vibrate for a short while and then
stop. If the implant stability (stiffness of the
bone–implant interface) increases, then the
vibration frequency of the sensor will increase.
Resistance to vibration of the transducer by the
surrounding bone is registered by a small computer device and measured in hertz. Hertz are
converted to ISQ (Implant Stability Quotient)

values ranging from 1 to 100; the higher the ISQ,
the greater the implant stability. This method
is known as RFA.13
Dentists feel better whenever an implant is
inserted using high torque (< 35 N cm). There
are some publications claiming that this is an
ultimate demand for immediate loading. However, using low insertion torques yields favorable
survival rates with optimal marginal bone levels
compared with the accepted norm.14
In 2004, the SPI implant system (Alpha-Bio
Tec, Petah Tikva, Israel) was introduced to the
dental market. The implant has an internal hexagon connection and is available in several
lengths and diameters. The implant surface is
sandblasted and acid-etched (NanoTec). Its
tapered core and sharp threads result in ﬁrm
bone grip, which enables stable insertion and
high primary stability.
The aim of this multicenter prospective study
was to evaluate the survival rate of implants
after insertion using low torque, by means of
recording measurements from RFA, probing
pocket depths and monitoring changes in the
interproximal crestal bone level.

Materials and methods
Study design

This prospective study was designed as a controlled multicenter clinical trial, and it involved
the participation of the following 4 medical
centers in China: West China Hospital of
Stomatology, Chengdu; Stomatology Hospital
of Shandong University, Jinan; Yantai Stomatological Hospital, Yantai; and Affiliated
Stomatology Hospital of Tongji University,
Shanghai.
The study was conducted in accordance
with the 1964 Declaration of Helsinki (and all
subsequent amendments) and Good Clinical
Practice (ISO 14155:2003). It was approved by
the ethics committee of Sichuan University
and was submitted to the other centers for
approval prior to commencement of the study.
The study was registered at www.clinicaltrials.
gov (registration No. NCT02367261).
Subjects and implants

Subjects were selected according to the following predetermined inclusion and exclusion
criteria:

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Inclusion criteria
1. Men and women over the age of 18 years
who were in need of 1–4 implants.
2. Patients able to understand the requirements of the study and willing and able to
comply with its instructions and schedules.
3. Patients who provided written informed
consent to participate in the study prior to
any study procedure.
4. Patients in good general health in the
opinion of the principal investigator, as
determined by the medical history and oral
examination.

24. Patients with any systemic condition that

Exclusion criteria
1. Immediately loaded implants.
2. Patients requiring bone augmentation.
3. Patients receiving treatment with bisphosphonates.
4. Patients receiving treatment with anticonvulsant drugs or anticoagulant drugs (international normalized ratio under 1.8).
5. Patients with untreated periodontal disease
and poor oral hygiene.
6. Patients with a history of alcohol, narcotic
or other drug abuse.
7. Patients undergoing steroid therapy.
8. Patients receiving radiotherapy, chemotherapy or any other immunosuppressive
treatment, or who had received radiotherapy in the last 5 years—patients who
had received radiotherapy to the head and
neck region at any time in the past.
9. Patients with metabolic bone disorders.
10. Patients with uncontrolled bleeding disorders, such as hemophilia, thrombocytopenia
and granulocytopenia.
11. Patients with degenerative diseases.
12. Patients with osteoradionecrosis.
13. Patients with renal failure.
14. Organ transplant recipients.
15. HIV-positive patients.
16. Patients with malignant diseases.
17. Patients with diseases that compromise the
immune system.
18. Patients with uncontrolled diabetes mellitus
(hemoglobin A1c level above 6.5%).
19. Patients with psychotic diseases.
20. Patients with hypersensitivity to any of the
components of the implant in general or to
titanium in particular.
21. Pregnant or lactating women.
22. Lack of patient cooperation.
23. Patients with uncontrolled endocrine
diseases.

The most important inclusion criteria were subjects over 18 years old who had good general
and dental health. The most important exclusion
criteria were as follows: immediate implantation, smokers of over 10 cigarettes a day,
alcohol abuse, various medical conditions as
specified by the clinician, and pregnant or
lactating women.

34 Volume 4 | Issue 2/2018

precluded surgical procedures.
25. Patients with parafunctional habits, such as
bruxism.
26. Patients with temporomandibular joint disease.
27. Patients with various pathologies of the oral
mucosa, such as benign mucous membrane
pemphigoid, desquamative gingivitis,
erosive lichen planus, oral malignancy and
bullous erosive diseases of the oral mucosa.
28. Patients who required ﬂapless procedures.
29. Patients who smoke over 10 cigarettes a day.

Surgical protocol

All subjects received 1–4 SPI implants. Using a
delayed implant approach, all implants were
inserted 4 months after tooth extraction. The
implants were 3. 3–5.0 mm in diameter and
8.0–13.0 mm in length. Implant surgeries were
performed under local anesthesia and followed
standard surgical techniques. After ﬂap elevation, the implant bed was prepared using
medical- grade stainless-steel drills (AlphaBio Tec) with progressively increasing diameter,
in accordance with the drilling protocol (Table 1).
The implant insertion torque was measured with
a physiodispenser machine (NSK, Stevenage,
U.K.; Nouvag, Goldach, Switzerland), which was
placed at the level of the crestal bone. RFA was
measured immediately after implant placement
using an Osstell device (Osstell, Gothenburg,
Sweden). A periapical radiograph was taken as
a baseline, using a paralleling technique.
Implants were exposed 4 months after
implantation, and RFA measurements were
taken immediately prior to connection of the
healing abutments. The ﬁnal prostheses were
fabricated 6 months post-implantation. The
occlusion of the restorations was adjusted, and
oral hygiene was reinforced with the patients.
Patients were recalled at intervals of 12 and 24
months after implant insertion surgery in order
to evaluate the periimplant bone level and the
status of the prosthetic work.

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Table 1

Implant ∅ (mm)

Soft bone (type IV; mm)

Medium bone (types II & III; mm)

Hard bone (type I; mm)

3.30

2.00

2.00

2.00

2.80

2.80
3.20 cortical

3.75

2.00

2.00

2.00

2.80

2.80

2.80

3.20

3.20
3.65 cortical

4.20

2.00

2.00

2.00

2.80

2.80

2.80

3.20

3.20

3.20

3.65

3.65
4.10 cortical

5.00

2.00

2.00

2.00

2.80

2.80

2.80

3.20

3.20

3.20

3.65

3.65

3.65

4.10

4.10

4.50

4.50
4.80 cortical

6.00

2.00

2.00

2.00

2.80

2.80

2.80

3.20

3.20

3.20

3.65

3.65

3.65

4.10

4.10

4.10

4.80

4.80

4.80

5.20

5.20
5.80 cortical

Cortical = Drill through cortical plate

Implant survival

Survival of implants was defined as those
implants that were still in place 24 months after
placement and that met the criteria set by Buser
et al.: the absence of persistent subjective complaints (e.g., pain, foreign-body sensation and
dysesthesia), the absence of periimplant infection with suppuration, the absence of mobility,
the absence of a persistent periimplant radiolucency, and the possibility of restoration.15

analyzed using ImageJ open software
(Version 1 . 33 , National Institutes of Health,
Bethesda, Md, U.S.) by an independent reader
who was blind to the study material. The implant
length was used as a reference measurement,
and bone level was therefore deﬁned as the distance from the reference point to the ﬁrst radiographic bone-to-implant contact; changes in
mesial and distal bone levels in this region were
considered to be remodeling. Mesial and distal
measurements were recorded and the mean of
these 2 values was used.

Bone level changes
Statistical analysis

Periapical radiographs with standardized
settings were taken as a baseline at the time of
implant surgery and were retaken at the time of
abutment connection and at 12 and 24 months
postsurgery (Figs. 1–3). Digital images were

Bone level was calculated as the average of the
mesial and distal levels at 3 time intervals (baseline and 12 and 24 months later). Repeated
measures general linear models with Bonferroni

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Table 1
The drilling protocol used in
the study.

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Low torque leads to minimal bone loss

Fig. 1

Fig. 1
SPI implant immediately after
implantation surgery.
Fig. 2
SPI implant 1 year after
implantation surgery.
Fig. 3
SPI implant 2 years after
implantation surgery.
Table 2
Insertion Torque During the
Implantation Surgery.

Fig. 2

Fig. 3

Variable

N (missing)

Mean ± SD (N cm)

Min, Max

Insertion torque

137 (0)

33.250 ± 9.913

5, 50

adjustment for multiple comparisons were used
to assess the differences between the 3 time
intervals. A similar analysis was performed for
pocket depths in 4 locations (buccal, lingual,
distal and mesial) at 3 time intervals (6, 12 and
24 months). P < 0.05 was considered statistically
signiﬁcant. All analyses were performed with
SPSS (Version 24, IBM Corp, Armonk, N.Y., U.S.).
The analysis set was as complete as possible and
was as close as possible to the intention-to-treat
ideal of including all subjects who had received
the therapy at least once.

Results
Eighty-eight patients out of 90 were included in
the study. Of the 88 treated subjects, 83 participated up to the 24-month follow-up mark
(2 patients had dropped out and 3 had implant
failure diagnosed). The study group consisted of
47.73% men and 52.27% women and the mean
age of the participants was 47.45 ± 11.15 years.
The majority did not smoke at all, and 22% of the
subjects smoked less than 10 cigarettes a day.
The average measurement for insertion
torque was 33.250 ± 9.913 N cm (Table 2). Of
137 implants, 132 survived. The calculated survival rate of the implants after 2 years was
96.5%. Five implants were lost during the ﬁrst
year of the study, while no implant was lost
during the second year.
RFA measurements were taken after implant
placement and retaken immediately prior to connection of the prostheses (Fig. 4). The mean immediate measurement for RFA was 74.92 ± 8.93,
while analysis at the time of implant exposure
4 months later yielded a 76.26 ± 7.42 mean score.
36 Volume 4 | Issue 2/2018

Changes in bone level
and soft tissue

The mean change in marginal bone level at the
1-year follow-up was 0.44 ± 0.52 mm and the
mean change at the 2-year follow-up was
0.54 ± 0.50 mm (Fig. 5). The average bone loss
between the 1- and 2-year follow-up marks was
calculated and found to be 0.105 mm.
Soft-tissue changes were monitored by
probing pocket depths at 4 locations: mesial,
distal, buccal and lingual (Fig. 6). The probing
depths before connection of the ﬁnal restoration averaged 1 . 04 ± 1 . 08 mm mesially,
0.91 ± 0.93 mm buccally, 1.04 ± 1.42 mm distally
and 0.86 ± 0.88 mm lingually. At 12 months
postsurgery, the average probing depths were
2.40 ± 0.80 mm, 2.08 ± 0.82 mm, 2.30 ± 0.85 mm
and 2.10 ± 0.80 mm, respectively. At 24 months
postsurgery, the average probing depths were
2.60 ± 1.05 mm, 2.10 ± 0.98 mm, 2.55 ± 1.11 mm
and 2.33 ± 1.20 mm, respectively.

Discussion
This was a controlled multicenter prospective
study that evaluated performance of the SPI
implant system with 24 months of follow-up.
The study demonstrated a stable survival rate
of 96.5% after 1 and 2 years of follow-up. This
ﬁnding correlates with previously performed
studies by Artzi et al.16 and Ormianer et al.17 that
showed similar implant survival rates of 96.95%
and 96.6%, respectively, over longer follow-up
periods.
According to Chrcanovic et al., failures of
dental implants can be subdivided into early and

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Table 2

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Low torque leads to minimal bone loss

Fig. 4

Fig. 5

Fig. 6

late failures, depending on whether they occur
either before/at abutment connection surgery
(early) or after occlusal loading of a prosthetic
restoration (late).18 Failures in each of these 2
distinct periods may be associated with different
factors. Early failure of an implant results from
an inability to establish intimate bone-toimplant contact. Based on our data, the excellent
stability and integration of SPI implants was
evident within 4 months after implantation
(before connection surgery), even though the
average insertion torque did not exceed 35 N cm.
The average insertion torque used in this
multicenter study yielded quite a low degree of
bone loss 2 years after implant insertion surgery.
The drilling protocol used in the study resulted
in a low insertion torque, accompanied by quite
a high RFA reading. The torque in this study is
much lower than the values reported in the
literature.19, 20 Lower insertion torques yield
favorable survival rates with optimal marginal
bone levels compared with the accepted
norm.14, 21 In contrast, studies in which high insertion torque was implemented demonstrated
signiﬁcant bone loss compared with low insertion torque.19, 20
In order to identify the risk factors associated
with implant failure, a multivariate Cox model
was formulated, and a rigorous model was
selected that was constructed with statistically

significant variables (P < 0.05) identified by
bivariate Cox regression analysis. As a result, 2
variables were statistically associated with
implant failure: tobacco use (P = 0.021) and
alcohol use (P = 0.047 ). In the multivariate
model, however, only tobacco use remained
statis tically associated with implant failure.
These results are in accordance with those of
several previous studies.18, 22, 23
The mean amount of bone loss detected in
the study was 0.426 mm at 1 year postimplantation and 0.531 mm at the 2-year mark. These
results are in agreement with those of Artzi
et al.16 and Ormianer et al.17, which reported bone
loss of 0.78 mm at the 3-year follow-up and
2.00 mm at the 9-year follow-up.
In addition, this minimal rate of bone loss
was accompanied by improved RFA measurements, which may be associated with increased
implant stability. The results suggest that the
SPI implants allowed progressive biological integration with their bony housing.
Probing depths before connection of the ﬁnal
restoration connection were 1.04 ± 1.08 mm
mesially, 0.91 ± 0.93 mm buccally, 1.04 ± 1.42 mm
distally and 0.86 ± 0.88 mm lingually. At 1 year
postimplantation, the probing depth measurements had increased to 2 . 40 ± 0. 80 mm,
2 . 08 ± 0 . 82 mm, 2 . 30 ± 0 . 85 mm and
2 .10 ± 0.80 mm, respectively, and at 2 years

Journal of
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Volume 4 | Issue 2/2018 37

Fig. 4
RFA measurements
immediately after
implantation and during
reopening surgery.
Fig. 5
Changes in bone loss over
time.
Fig. 6
Changes in pocket depth at
4 locations over time.

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Low torque leads to minimal bone loss

postimplantation, they had increased to
2.60 ± 1.05 mm, 2.10 ± 0.98 mm, 2.55 ± 1.11 mm
and 2.33 ± 1.20 mm, respectively.
The analysis thus revealed that probing
depths increased moderately compared with the
baseline over the period of the study, and one
may conclude that a more fastidious oral hygiene
regimen was required by all subjects, especially
with regard to the implant sites, even though
bone loss measurements were not found to be
higher at these sites. None of the implants were
diagnosed with periimplant mucositis or periimplantitis, according to the diagnostic criteria,24
such as bleeding on probing.

Conclusion
Within the limits of the study, implants inserted
with low torque displayed high RFA scores,
minimal bone loss and a high survival rate at
24 months after implantation.

Competing interests
The authors declare that there are no competing
interests. Prof. Ofer Moses serves as an external
medical adviser for Alpha-Bio Tec. The study
was funded by Alpha-Bio Tec.

References
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[39] => JOSR_2_2018_web.pdf

[40] => JOSR_2_2018_web.pdf

conometric retention for fixed prosthesis

Implant-supported mandibular complete
fixed prosthesis with conometric retention
after 3 years of functional loading

Abstract

Objective
Eriberto Bressan,a Michele Stocchero,a, b Maddalena Buso,a
Edoardo Stellini,a Francesco Saverio Ludovichettia, c &
Diego Lopsa, d
a

Department of Neurosciences, University of Padua,
Padua, Italy
b
Department of Oral and Maxillofacial Surgery and Oral
Medicine, Faculty of Odontology, Malmö University,
Malmö, Sweden
c
Department of Dental Materials and Prosthodontics,
School of Dentistry, São Paulo State University,
Araraquara, Brazil
d
Department of Prosthodontics, Dental Clinic, School of
Dentistry, University of Milan, Milan, Italy

Corresponding author:
Dr. Francesco Saverio Ludovichetti
Department of Neurosciences
University of Padua
Via Giustiniani 2
35128 Padua
Italy
T +39 340 8573561
f.ludovichetti@gmail.com
How to cite this article:
Bressan E, Stocchero M, Buso M, Stellini E, Ludovichetti
FS, Lops D. Implant-supported mandibular complete
ﬁxed prosthesis with conometric retention after 3 years
of functional loading.
J Oral Science Rehabilitation. 2018 Jun;4(2):40–45.

The aim of the study was to assess the clinical performance of
implant-supported mandibular complete ﬁxed prostheses with conometric retention after 3 years of functional loading.
Materials and methods

In this retrospective study, patients treated with implant-supported
mandibular complete ﬁxed prostheses with conometric retention were
considered. Standardized radiographic examinations were performed to
assess the marginal bone. Radiographs were acquired at the time of
prosthesis insertion and at the 3-year follow-up, and marginal bone loss
was calculated. The occurrence of implant failures, and biological and
technical complications was registered.
Results

Thirty-nine patients were selected. At the 3-year follow-up, 134 out of
the 160 placed implants did not show any marginal bone loss and 4 of
them had been lost. The percentage of restorations free of technical
complications was 71.8% during the entire follow-up period. Complications that occurred in restorations were as follows: veneer fracture (n = 4),
framework fracture (n = 3), loss of retention (n = 2) and need for relining
(n = 2). Mucositis was recorded in 1 patient and it was successfully
treated.
Conclusion

The clinical performance of implant-supported mandibular complete
ﬁxed prostheses with conometric retention after 3 years of functional
loading showed a low rate of marginal bone loss and technical complications. Owing to the easy retrievability, all complications were successfully treated.
Keywords

Fixed prostheses; dental implants; conometric retention; edentulous
mandible.
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conometric retention for fixed prosthesis

Introduction

survival, marginal bone loss and incidence of
technical complications.

The rehabilitation of edentate patients with the
use of implant-supported fixed dental prostheses (IFDPs) has shown high long-term survival rates, comparable to those of tooth-borne
restorations.1 The clinical success, however,
depends on the extent of biological and technical
complications occurring throughout the period
of function.2 According to a systematic review,
the patient-centered estimated 5-year complication rate for IFDPs was 33.6%.3 Such issues
can be better addressed when restorations can
be easily removed. Thus, a remarkable research
effort has been dedicated to protocols with
enhanced retrievability. 4
One of the major topics of discussion among
researchers and clinicians is the type of ﬁxation
between the implant and the prosthesis. Such
connection is commonly provided by means of
screws or cement. None of the ﬁxation methods
has been found to be clearly advantageous over
the other.5 Moreover, they typically show some
drawbacks. Screw-retained prostheses tend to
experience more technical complications, such as
screw loosening and fractures, while cemented
restorations exhibit more biological complications,
such as implant loss and marginal bone loss.2
Recently, the conometric connection was
proposed as a ﬁxation system for IFDPs. Such a
system is composed of a tapered coping ﬁxed to
the prosthesis and inserted into a tapered abutment. When a suitable insertion force is applied,
this system is capable of providing a ﬁxed connection.6 Such retention is based on the friction
between the components, without the use of
cement. The clinical use of the conometric retention has been described for implant-supported
complete7 and partial8 ﬁxed prostheses.
One of the reported advantages of a conometric connection system is the retrievability of
the restoration.7 Conometric-retained prostheses can be easily removed by the operator in
order to check the periimplant soft-tissue status
and for periodic hygiene procedures. Despite the
promising results in terms of clinical success,
long-term studies on mandibular full-arch
conometric-retained restorations with a larger
study population are lacking in the current literature. Thus, the aim of the present retrospective
study was to assess the clinical performance of
implant-supported mandibular complete ﬁxed
prostheses with conometric retention after
3 years of functional loading. Outcomes were
evaluated in terms of implant and prosthetic

Materials and methods
In this retrospective study, patients consecutively treated with implant-supported mandibular complete ﬁxed prostheses with conometric
retention were selected. The IFDPs were supported by 4 mandibular implants placed in each
patient. All cases were treated in a single center
and had 3 years of follow-up from the time of
prosthesis delivery. This study was conducted
according to the principles of the Declaration of
Helsinki on human medical experimentation. All
patients signed informed consent prior to the
implant treatment.
The adopted surgical and prosthetic protocol
has been described in a previous study.7 After
prosthetic delivery (baseline, T0), patients were
recalled at 6 months, 1 year, 2 years and 3 years
(T3) for follow-up visits. At each visit, the prosthesis was removed and oral hygiene, implant
maintenance and patient-centered motivational
instruction were delivered. Data were extracted
from patient ﬁles at T3. Variables were subdivided between patient-based and implant-based.
The following patient demographic characteristics were reported: sex, age at the time of
surgery, smoking habit, bruxism, drug intake,
systemic disease and time of prosthetic loading.
Implant information, such as diameter and
length, were recorded. Moreover, intraforaminal
(positions .1, .2, .3, .4) or extraforaminal (positions
.5, .6, .7) implant position was recorded (Fig. 1).
Implant failure and technical complications, such
as loss of retention, veneer fracture, need for
relining and framework fracture, that occurred
during the period of function were recorded.
Standardized radiographic examinations with the
use of a Rinn Universal Collimator (Dentsply
Sirona, York, Pa., U.S.) were performed to assess
the marginal bone. Radiographs were acquired
at T0 and at T3. For marginal bone assessments,
ImageJ software (Version 1.48, National Institutes of Health, Bethesda, Md., U.S.) was used.
The measurements were performed with a
precision of 0.01 mm at a 7× digital magniﬁcation
level. For each analyzed radiograph, measurement calibration was carried out using the diameter and length of the implant. Then, the distance
from the implant shoulder to the ﬁrst appreciable contact point between the bone and implant
was measured. In cases where the marginal bone
level was coronal or at the level of the implant

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conometric retention for fixed prosthesis

Fig. 1

Fig. 1
Number of implants based
on diameter and length.
The intra-arch position is
distinguished.

shoulder, the reported value was 0 mm. The
measurement was performed both medial and
distal to the implant. The mean mesial and distal
values were calculated at T0 and T3. The radiographic analysis was performed in a blind manner
by 1 experienced examiner not involved in the
study. Marginal bone loss (MBL) was calculated
as the difference between the 2 time points.
According to the MBL results, patient-based
variables were subdivided in 2 categories:
patients with no MBL and patients who presented with MBL (Table 1). In the same manner,
implant-based variables were subdivided into
the following categories: implants with no MBL,
implants with an MBL of < 1 mm, implants with
an MBL of between 1 and 2 mm, implants with
an MBL of > 2 mm, and implant failure (Table 2).
Moreover, the incidence of technical complications was calculated.
Results
Thirty-nine patients (19 men and 20 women)
were enrolled in the study. Demographic characteristics are shown in Table 1. A total of 160
implants were placed, 98 intraforaminally and
62 extraforaminally (Fig. 1). There was no sign of
MBL around 83.75% of the implants, while 2.5%
were lost during the 3-year follow-up. Implantbased variables according to MBL can be found
in Table 2. Mucositis in 1 patient was encountered
during periodic follow-up (Fig. 2). Regarding the
restorations, 71.8% were free of technical complications during the entire follow-up period.
Complications that occurred in restorations were
42 Volume 4 | Issue 2/2018

veneer fracture, framework fracture, loss of
retention and need for relining (Table 3; Fig. 3).
Discussion
In the present retrospective study, 39 patients
with complete mandibular edentulism were rehabilitated with implant-supported conometricretained prostheses. Our aim was to report the
clinical performance in terms of incidence of
technical and biological complications in a 3-year
follow-up period. For this purpose, we included
data on both immediate and delayed loading.
The rehabilitation of edentate mandibles with
implant-supported ﬁxed restoration has been
reported in long-term studies since the 1990s.9
Despite the high success rates after 15 years,
several surgical and prosthetic procedures have
been introduced over the years in terms of
number of supporting implants, intra-arch locations, time of loading, and type of connection
between the implant and the prosthesis.10
A meta-analysis on mandibular IFDPs11 investigated the implant survival rate of restorations
supported by a range of 4–9 implants. In that
study, 17 trials, including 501 patients and 2,827
implants, were considered. According to the
results, intraforaminal implant placement was the
most common technique (88.5% of all implants).
In the present study, all restorations were supported by 4 implants, which were placed either
intraforaminally or extraforaminally. Implants in
the distal position were placed posterior to the
mental foramen whenever the bone amount was
sufficient in order to reduce the distal cantilever.

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conometric retention for fixed prosthesis

Table 1

Patients without MBL

Patients with MBL

Total

Number

26 (66.6%)

13 (33.3%)

39

Average age

67.88

64.33

66.1

YES

5

7

12

NO

21

6

27

YES

2

7

9

NO

24

6

30

NO

8

5

13

Oral bisphosphonates

4

0

4

Antihypertensive

13

7

20

Antiplatelet

4

5

9

1

3

Smoker
Bruxism

Drugs

Diabetes control drugs

Disease

Loading

Anti-arrhythmic

1

0

1

NO

8

3

11

Hypertension

14

7

21

Hypercholesterolemia

1

3

4

Diabetes

8

2

10

Cardiovascular disease

14

3

17

Immediate

17 (77.3%)

5 (22.7%)

22

Delayed

9 (53%)

8 (47%)

17

MBL = marginal bone loss.
Table 2

Implants
without MBL (mm)

Position
Loading

Table 3

Implants with MBL (mm)
0 < MBL < 1

1 < MBL < 2

MBL > 2

Implant
failures

Total

Number

134 (83.75%)

13 (8.12%)

7 (4.37%)

2 (1.25%)

4 (2.50%)

160

Intraforaminal

82

8

5

1

2

98

Extraforaminal

52

5

2

1

2

62

Immediate

80

6

2

88

Delayed

54

7

2

72

Free of complications
Technical complications

7

2

28 (71.8%)
Veneer fracture

4 (10.24%)

Framework fracture

3 (7.68%)

Loss of retention

2 (5.12%)

Need for relining

2 (5.12%)

The majority of implants were placed in the intraforaminal area; however, 62 implants were placed
distal to the foramen. A total of 33 restorations
were supported by at least 2 extraforaminal
implants. This means that in the majority of cases
(65%) the placement of implants of at least 8 mm
in length was possible in the distal sites. This is in
accordance with a recent study that evaluated the
dimensions of the alveolar ridge in the edentulous
posterior mandible12 based on CBCT data. A mean
bone height of 11.20 mm and 10.28 mm in the sites

of the second premolar and mesial root of the ﬁrst
molar, respectively, was measured.
During the present 3-year follow-up study,
4 out of 160 implants failed. Therefore, the overall implant survival rate was 97.5%. In all cases,
implants were lost during the ﬁrst year after
placement. This result is in accordance with
recent studies with similar groups of patients
and follow-up.13, 14 In addition, a systematic
review showed similar results.11 In the study, the
cumulative implant survival rate estimates were

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Table 1
Patient demographic
characteristics and patientbased variables. Data are
shown as frequency
(percentage of the total).
Table 2
Implant-based variables
according to marginal
bone loss (MBL) and implant
failure.
Table 3
Occurrence of technical
complications in the
restorations. Data are shown
as frequency (percentage
of the total).

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conometric retention for fixed prosthesis

Fig. 2

Fig. 3

Fig. 2
One patient presented with
periimplant mucositis
affecting 2 implants
(in positions #32 and 35).
This biological complication
was successfully treated
with interceptive supportive
therapy.
Fig. 3
The most severe technical
complication encountered in
this study was framework
fracture. Two cases in which
a crack occurred in the distal
cantilever are shown.

calculated based on the number of supporting
implants for mandibular full-arch restorations.
At the 5 -year endpoint for restorations supported on 4 implants, the implant survival rate
was 97.65% (95% CI: 94.48–100). Regarding
biological complications, a good performance in
terms of incidence of MBL was observed in the
present study, since 134 out of the 156 surviving
implants (85.9%) did not show any MBL after
the 3-year follow-up. However, as previous
studies observed, the stability of marginal bone
is related to patient-related factors.15
From our results, a relevant difference in the
incidence of MBL was observed based on smoking habit, since it occurred in 58.30% of the smoking patients, while it occurred only in 28.57% of
the nonsmoking patients. It is well known that
placing implants in smoking patients has always
been a challenging situation, as many clinical
studies have shown a lower implant success rate
in this regard. In a systematic review on the effect
of smoking habit,16 15 observational studies with
a follow-up period ranging from 8 to 240 months
were included. A total of 5,840 implants placed
in smoking patients were compared with 14, 683
placed in nonsmoking patients. The authors concluded that the risk of MBL is higher in smokers,
especially in the maxillary bone.16
In the present study, at periodic follow-up
visits, the prostheses were removed in order to
check the periimplant soft-tissue status. Mucositis affecting two implants was successfully
treated with interceptive supportive therapy.
The protocol adopted consisted of professional
oral hygiene followed by the use of a 0.2% chlorhexidine mouthrinse 3 times per day for 2 weeks.
Therefore, the easy retrievability of the restoration facilitated primary and secondary prevention of periimplant diseases.
It is well known that occurrence of complications for full-arch restoration is relevant.2, 17 In
a systematic review by Papaspyridakos et al., the
cumulative rate of prostheses free of compli44 Volume 4 | Issue 2/2018

cations was 29.3% at the 5-year follow-up.11
Interestingly, the estimated cumulative rates of
screw fracture and screw loosening complications were 10.4% and 9.3%, respectively. In contrast, in the present study, the percentage of
restorations free of technical complications was
71.8% at 3 years. A reason for this result could
be the prosthetic design adopted: The avoidance
of screws might have had a major role in decreasing the incidence of technical complications.
The most severe technical complication
encountered in this study was framework fracture. Cracks were located in the distal cantilever
in all 3 cases. This result is not surprising, since
it is generally accepted that the incidence rate
of prosthetic complications is increased dramatically when distal extensions are applied.18 In
cases of framework fracture, the prosthesis was
removed and then repaired. In order to reduce
this occurrence, a distal cantilever is to be
avoided whenever anatomical structures allow
it. Thus, the positioning of distal implants posterior to the mental foramen is advocated.
Interestingly, all patients in which framework
fractures occurred were bruxers. These results
are in accordance with previous studies found
in the literature in which many prosthodontic
failures were associated with bruxism.19, 20 Other
minor technical complications were veneer fracture (n = 4), loss of retention (n = 2) and need for
relining (n = 2). In all cases, the problem was
addressed after easy removal. Direct veneer
repair, coping replacement and indirect relining
were provided respectively.
One major limitation of the study was that
immediate and delayed loading restorations
were included in the same study. However, since
the aim of this study was to record the performance of a speciﬁc prosthetic protocol, it is
believed that different clinical procedures could
give a wider picture. Moreover, the substantially
similar behavior of immediate and delayed loading implants justiﬁes a direct comparison.

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conometric retention for fixed prosthesis

With the present retrospective study, a good
clinical performance after 3 years of follow-up
in terms of survival rate, marginal bone resorption, and incidence of biological and technical
complications was observed. One of the major
advantages was the effortless retrievability of
the restoration, which facilitated primary and
secondary prevention. As a matter of fact, with
the periodic prosthesis removal for routine
hygiene procedures, periimplant disease at early
stages could be intercepted and technical complications could be easily solved.

complete fixed prostheses with conometric
retention after 3 years of functional loading
showed a low rate of MBL and technical complications. Owing to the easy retrievability of the
system, all complications were successfully
addressed. A careful patient selection must be
undertaken, since bruxism and distal cantilever
may represent risk factors for major technical
complications such as framework fracture. The
efficacy of this treatment option in terms of cost
and maintenance has to be conﬁrmed by multicenter, longer-term studies.

Conclusion

Competing interests

Within the limitations of the study, the clinical The authors declare that they have no competperformance of implant-supported mandibular ing interests.

References
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6.
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3.
Pjetursson BE, Thoma D, Jung R,
Zwahlen M, Zembic A. A systematic
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→ Clin Oral Implants Res.
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8.
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4.
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prosthesis: a digitally designed
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9.
Lindquist LW, Carlsson GE, Jemt T. A
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by osseointegrated implants. Clinical
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5.
Shadid R, Sadaqa N. A comparison
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10.
Weber HP, Morton D, Gallucci GO,
Roccuzzo M, Cordaro L, Grutter L.
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loading protocols.
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12.
Bressan E, Ferrarese N, Pramstraller M,
Lops D, Farina R, Tomasi C. Ridge
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in posterior sextants: an observational
study on cone beam computed
tomography radiographs.
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2017 Feb;26(1):66–72.
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Sanz M, Ivanoff CJ, Weingart D, Wiltfang
J, Gahlert M, Cordaro L, Ganeles J,
Bragger U, Jackowski J, Martin WC, Jung
RE, Chen S, Hammerle C. Clinical and
radiologic outcomes after submerged
and transmucosal implant placement
with two-piece implants in the anterior
maxilla and mandible: 3-year results
of a randomized controlled clinical trial.
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2015 Apr;17(2):234–46.
14.
Agliardi EL, Pozzi A, Stappert CF, Benzi R,
Romeo D, Gherlone E. Immediate ﬁxed
rehabilitation of the edentulous maxilla:
a prospective clinical and radiological
study after 3 years of loading.
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2014 Apr;16(2):292–302.
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Herrmann I, Lekholm U, Holm S, Kultje C.
Evaluation of patient and implant
characteristics as potential prognostic
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→ Int J Oral Maxillofac Implants.
2005 Mar–Apr;20(2):220–30.

16.
Chrcanovic BR, Albrektsson T,
Wennerberg A. Smoking and dental
implants: a systematic review and
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2015 May;43(5):487–98.
17.
Aglietta M, Siciliano VI, Zwahlen M,
Bragger U, Pjetursson BE, Lang NP, Salvi
GE. A systematic review of the survival
and complication rates of implant
supported ﬁxed dental prostheses with
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18.
Brägger U, Hirt-Steiner S, Schnell N,
Schmidlin K, Salvi GE, Pjetursson B,
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2011 Jan;22(1):70–7.
19.
Mikeli A, Walter MH. Impact of bruxism
on ceramic defects in implant-borne ﬁxed
dental prostheses: a retrospective study.
→ Int J Prosthodont.
2016 May–Jun;29(3):296–8.
20.
Chrcanovic BR, Kisch J, Albrektsson T,
Wennerberg A. Bruxism and dental
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11.
Papaspyridakos P, Mokti M, Chen CJ,
Benic GI, Gallucci GO, Chronopoulos V.
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Te m p o r o m a n d i b u l a r j o i n t d y s f u n c t i o n

Evaluation of the incidence and
prevalence of temporomandibular joint
dysfunction in psychiatric patients using
typical antipsychotic drugs
Abstract
Objective
Elizabeth Maria Costa de Carvalho,a
Gustavo Alves Oliveira Barbosa,a Ana Cristina Rosario
Sobreira Vasconcellos,a Roberto Correia de Araujoa
& Antonio Fernando Pereira Falcaoa
a

Federal University of Bahia School of Dentistry,
Salvador, Brazil

Corresponding author:
Prof. Ana Cristina Rosario Sobreira Vasconcellos
Alameda Marine, n. 60
Apto 202, STIEP
Salvador, Bahia, CEP:41770-84
Brasil
anacristina_sobreira@yahoo.com.br
T +55 71 99187 7328
How to cite this article:
Costa de Carvalho EM, Oliveira Barbosa GA, Rosario
Sobreira Vasconcellos AC, Correia de Araujo R, Periera
Falcao AF. Evaluation of the incidence and prevalence
of temporomandibular joint dysfunction in psychiatric
patients using typical antipsychotic drugs.
J Oral Science Rehabilitation. 2018 Jun;4(2):46–53.

The aim of this study was to identify and classify temporomandibular
joint dysfunction (TMJD) in psychiatric patients using typical antipsychotics compared with healthy individuals, both physically and mentally.
Materials and methods

The present study had a descriptive cross-sectional design, developed
over a 6-month period, at the Teaching Assistant Nucleus of Dentistry
and Mental Health affiliated with the Juliano Moreira Psychiatric
Hospital, Salvador, Brazil, and the Federal University of Bahia School of
Dentistry, Salvador, Brazil. To that end, 120 patients aged 18 years or
older, 40 psychiatric patients (20 women and 20 men), all using typical
or ﬁrst-generation antipsychotics of the pharmacological groups of butyrophenones and phenothiazines, and 80 mentally healthy patients (40
women and 40 men), underwent assessment of TMJD severity through
an Anamnestic Index.
Results

There were statistically signiﬁcant differences in the prevalence of TMJD
in the group of patients with mental illness. Among the 40 individuals
with mental and behavioral disorders, moderate TMJD was the most
prevalent (16/40.0%), but in the control group, there was a higher
prevalence of mild TMJD (34/42.5%). Two cases of severe TMJD were
diagnosed in psychiatric patients.
Conclusion

In this study, it was possible to identify the prevalence and incidence of
TMJD among those with mental and behavioral disorders using typical
antipsychotic drugs, justifying the importance of their monitoring for
TMJD. However, owing to its subjective nature, these patients should be
referred for a specialized examination to conﬁrm the diagnosis of TMJD.
Keywords

Temporomandibular joint dysfunction; mental disorder; psychiatric care.
46 Volume 4 | Issue 2/2018

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Te m p o r o m a n d i b u l a r j o i n t d y s f u n c t i o n

Introduction
Every human being may present with some kind
of psychopathological disorder throughout his
or her life, and may or may not seek help, and in
some cases, the disorder may not be resolved.
Each individual constructs within himself or
herself a mental organization capable of making
frequent adaptations to the outside world, and
performing these tasks requires a continuous
functioning of regulatory and adaptive mechanisms. The proper development of these
mechanisms leads the individual to develop a
personality within normal patterns. However, if
there is an imbalance of these mechanisms,
mental and behavioral disorders may occur.1
The oral health of patients with psychiatric
disorders is generally more impaired than that
of the general population, mainly owing to the
precariousness of oral hygiene associated with
nonreality and the side effects of the psychotropic drugs used in treatment that affect
psychomotor performance, salivary ﬂow and
oral soft tissue. Antipsychotic therapy may
increase the risk and duration of oral disease,
since these drugs are used for a long period, thus
justifying the establishment of preventive/
educational oral health programs.2, 3
Schizophrenic disorders affect about 1% of
the general population and are a major problem
for health services, since high rates of recurrence
and comorbidity may require high long-term
costs for the individual, family and society.3, 4 The
treatment of schizophrenia often involves antipsychotics (APs) of 2 pharmacological groups:
typical and atypical. Typical or conventional
ﬁrst-generation APs represented by dopamine
(D2) antagonists—phenothiazine derivatives (such
as chlorpromazine) were used initially, and later,
in the 1950s, butyrophenone derivatives (such as
haloperidol) were introduced—mainly eliminate
the psychotic symptoms of schizophrenia.
Second-generation, atypical or new-generation
APs are APs with speciﬁc characteristics, such
as minimal extrapyramidal effects, low sedation
and rapid dissociation of D 2 receptors; these
properties are postulated to be due to the blockade of serotonergic and dopaminergic receptors
and have a more favorable effect on the negative
(chronic) symptoms, which results in an improvement in patients’ quality of life. 4 Therefore, in
patients treated with atypical APs, better
hygiene of the oral cavity is expected. In addition,
disorders of the oral cavity are exacerbated by a
decrease in salivary secretion, mainly caused by

typical APs, but also a side effect of some atypical
APs, such as risperidone. 5–7
The scientiﬁc literature has reported that
those with mental disorders do not have access
to adequate dental care owing to dental professionals’ lack of knowledge of how to assist
patients with mental disorders, as well as fear,
stigma or negative attitudes on behalf of
dentists.5 Generally, such patients have poor oral
hygiene, a high number of decayed or missing
teeth, bad breath, inﬂammation of the gingival
tissue, and, in more severe cases, edentulism
and a tendency toward temporomandibular joint
dysfunction (TMJD).6 Orofacial movement disorders associated with daily use of psychoactive
drugs, particularly typical APs, may have repercussions for the temporomandibular joint (TMJ)
and lead to TMJD.7
Although TMJD does not have a definite
etiology, its appearance is credited to functional,
structural and psychological factors. Conditions
such as malocclusion, parafunction and modiﬁcation of the emotional state (stress) may be
present in patients with this dysfunction. The
signs and symptoms of TMJD are characterized
by TMJ pain and painful masticatory muscles;
headache; otological manifestations, such as
tinnitus, auricular fullness, vertigo and auditory
symptoms; limitation and/or lack of coordination
of mandibular movements; limitation of mouth
opening; temporary joint blockage; and joint
crackling. 8 Therefore, the morphological and
functional disorders of the oral cavity inﬂuence
the skeletal-motor action of the masticatory
muscles, leading to a breakdown of the orofacial
anatomical and neurological homeostasis, and
affecting not only the stomatognathic system
but also the general health of the patient.7
Oromandibular dystonia can be diagnosed
by the contractions of the jaw, compromised
phonation and swallowing. In severe cases, it
may cause bilateral displacement of the TMJ.9
The etiology of TMJD is considered complex
and multifactorial, with the presence of predisposing, initial and perpetuating factors. Such conditions follow an evolutionary course of days, months
or years, occasionally transient and self-limiting,
and aggravated by parafunctional habits.10
Given the strong suspicion of the correlation
between TMJD and psychiatric patients and the
limited scientific literature on the topic, the
objective of this research was to identify and
classify TMJD in psychiatric patients using typical APs, using the Anamnestic Index advocated
by Fonseca in 1994.¹¹

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Te m p o r o m a n d i b u l a r j o i n t d y s f u n c t i o n

Materials and methods
This study was conducted in accordance with
the norms of Resolution No. 466/ 12 of the
National Health Council of the Ministry of Health,
published on December 12, 2012, and by the Code
of Professional Dental Ethics, according to Resolution No. 179/1993 of the Federal Council of
Dentistry. The project was submitted to the
Research Ethics Committee of the School of Dentistry of the Federal University of Bahia, Salvador,
Brazil, and approved by CONEP under registration CAAE 08119812.0.0000.5024, dated April
14, 2015, Consubstantiated Opinion No. 1023044.
The participants in the test group—40 psychiatric patients, 20 women and 20 men, users
of typical APs of the pharmacological grouping
of butyrophenones and phenothiazines—were
examined at the Teaching Assistant Nucleus of
Dentistry and Mental Health affiliated with the
Juliano Moreira Psychiatric Hospital, Salvador,
Brazil, and the Federal University of Bahia School
of Dentistry, Salvador, Brazil. The evaluation of
the oral health of the participants in the control
group—80 volunteers, 40 women and 40 men
clinically healthy from a psychiatric point of
view—was carried out at the periodontic clinic
of the Federal University of Bahia.
A population of patients with mental and
behavioral disorders institutionalized at the
Juliano Moreira Psychiatric Hospital, users of typical APs drugs, composed of 10 participants, were
evaluated. However, because it was an investigation with psychiatric patients, who, in some situations, do not cooperate to allow the performance
of this type of examination, the sample size was
chosen by convenience sample, based on the
number of individuals who fulﬁlled the necessary
requirements to participate, respecting the exclusion and inclusion criteria established.
The inclusion criteria common to the 2 groups
analyzed were: age greater than or equal to 18
years, acceptance to participate and signing of
the free and informed consent. For the test group,
the following inclusion criteria were also considered: being assisted at the Juliano Moreira Psychiatric Hospital, regardless of the assistance
model; being a typical AP user; for ethical-legal
reasons, the person responsible and/or the companion signed the informed consent in the case
of patients assisted in an outpatient clinic, and for
internees, the acceptance was by the chief nurse.
The present study had a descriptive crosssectional design and data collection started in
May 2015 and ended in October 2015.
48 Volume 4 | Issue 2/2018

The Anamnestic Index advocated by Fonseca
(IAF)¹¹ was used in this study as a screening
instrument aimed primarily at classifying the
severity of TMJD symptoms, with an accessible
language to be self-completed; however, owing
to the fact that the sample was made up of mentally ill patients assisted in a public psychiatric
hospital, the interviews for data collection were
performed in the presence of the caregiver or the
nurse, in the case of hospitalized patients. The
IAF consists of 10 questions that verify the presence of TMJ pain in the neck, headache, masticatory and movement difficulties, crackles, parafunctional habits, perception of malocclusion and
feelings of emotional stress.7 It allows 3 types of
responses—yes, sometimes or no—with scoring
equivalent to 10, 5 and 0, respectively. By aggregating the points, the index classiﬁes participants into these categories of symptom severity:
(I) no TMJD: 0–15 points
(II) mild TMJD: 20–40 points
(III) moderate TMJD: 45–65 points
(IV) severe TMJD: 70–100 points
Despite its subjective nature, it can be considered as indicative of the need for more accurate tests to confirm the severity of TMJD
impairment in patients who present with signs
or symptoms compatible with TMJD.15
The IAF was chosen because it is a suitable
tool for the study of population profiles for
TMJD symptoms and for screening potential
patients, aiming at the later application of more
accurate diagnostic indexes and tests for
TMJD—the Diagnostic Criteria for Research on
Temporomandibular Disorders.
Statistical analysis

The chi-square (Pearson), Fisher exact and
Mann–Whitney test were used for the statistical
analysis of the categorical variables. The parametric variables were submitted to the Pearson
correlation test and the nonparametric variables
to the Spearman correlation test.
All 120 records from the 40 patients with
mental and behavioral disorders (test group) and
80 data records from the mentally healthy participants (control group) were included. The data
related to the dental clinic record were tabulated
in the EpiData program (Version 3.1, EpiData
Association, Odense, Denmark) and transferred
to the Excel 2010 program for further exploratory analysis, performed through the SPSS for
Windows statistical program (Version 13.0,
SPSS, Chicago, Ill., U.S.).

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Table 1

Test group

Age

Ethnic group

%

Quantity

%

Quantity

%

Male

20

50.0

40

50.0

60

50.0

Female

20

50.0

40

50.0

60

50.0

18–34

9

22.5

22

27.5

31

25.8

≥ 35

31

77.5

58

72.5

89

74.2

White/brown

20

50.0

47

58.8

67

55.8

Black

20

50.0

32

40.0

52

43.4

1

1.2

1

0.8

Not declared
Education

Individual monthly income

Total

Quantity

Group Variable
Sex

Control group

≥ 9 years

10

25.0

67

83.7

77

64.2

< 9 years

30

75.0

13

16.3

43

35.8

≤ minimum wage

32

80.0

44

55.0

76

63.3

> minimum wage

8

20.0

33

41.2

41

34.2

3

3.8

3

2.5

No income

For the descriptive step, we calculated the absolute and relative frequencies, and the measures
of central tendency and dispersion presented by
means of tables. For the exploratory analysis,
the Pearson chi-square association test was
used to verify the differences between the 2
groups. For the analyses, a conﬁdence level of
95% and a value of P < 0.05 were considered.
Odds ratios and conﬁdence intervals were calculated as signiﬁcant values of P < 0.05.
For statistical inferences, when the variables
presented dependence, that is, when comparing
different moments of the same group (test
group), the Mann–Whitney test was used for
the independent variables, such as in the cases
of normality patterns obtained from the asymptomatic participants of the control group, or in
the comparisons between the test group and
the control group. The decision to use nonparametric tests was due to the small sample size.

Results
According to the entries in the medical records
of the 40 patients in the test group—13 of them
hospitalized and 27 treated on an outpatient
basis, some of whom had more than 1 diagnosis—obtained from the statistical medical
archiving service of the hospital, 63.3% had
schizophrenia and schizotypal and delusional
disorders; 24. 5% mood disorders (affective);
8.1% mental retardation and 4.1% schizophrenic-type organic delusional disorder, including
World Health Organization ( 1996) coding for
each of these disorders.

The characterization of the sample analyzed in
this study considered the following sociodemographic variables: sex, age group, ethnic group,
educational level and individual monthly income
(Table 1). The sex of the participants was equally
distributed: 50% men and 50% women. As for
the ethnic group, 50% were white/brown and
50% were black. The majority of the participants
(77.5%) were over 35 years old, with a monthly
income equal to or less than the minimum wage
effective in 2013, in the state of Bahia (80%). The
educational level of the participants showed a
higher percentage of individuals who had not
completed 9 years of study: 75%. From these
ﬁndings, it can be inferred that, probably, for
those with mental disorders and behavioral users
of psychoactive drugs, access to school would
have been restricted to basic education because
of the limitations that the mental pathologies
impose, as well as the extrapyramidal effects of
APs typical for psychiatric treatment, which may
compromise motor coordination.
The assessment of the degree of severity of
TMJD was performed with the application of
the IAF Test 15, and the data obtained in this
research demonstrated statistically signiﬁcant
differences when comparing the presence of
TMJD among patients with mental illness to
among mentally healthy volunteers: 82.5% of
the former had a higher prevalence of TMJD,
irrespective of the degree of severity of the dysfunction, and the dysfunction was diagnosed in
55.0% of the volunteers in the control group.
Regarding the degree of TMJD severity as
suggested by FONSECA , statistically signiﬁcant
differences were identiﬁed between the test and

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Table 1
Absolute and relative values
of the sample according to
sociodemographic variables.

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Mild
TMJD Group

Moderate

Severe

Table 2

Absent

Number

%

Number

%

Number

%

Number

%

Test

15

37.5

16

40.0

2

5.0

7

17.5

Control

34

42.5

10

12.5

0

0

36

45.0

Total

49

40.8

26

21.7

2

1.7

43

35.8

* P = 0.001.

Table 2
Absolute and relative values of
the sample according to
severity of temporomandibular
dysfunction.

control groups (P = 0.001). A mild degree of TMJD
was recorded in 37.5% of the participants in the
test group and 42.5% in the control group; moderate TMJD was diagnosed in 40.0% of the individuals in the test group and 12.5% in the control
group; and the only clinical cases of severe TMJD
were identiﬁed in 2 patients with mental and
behavioral disorders (5.0%); 17.5% of the participants in the test group and 45.0% of the control
group did not present with TMJD (Table 2).
In the analysis of the association between the
possible risk factors for the occurrence of TMJD
in the 120 participants and the sociodemographic
variables, only a statistically signiﬁcant correlation was registered considering the different
degrees of TMJD severity and ethnic group
(P = 0.025), both in the test and in the control
groups. Moderate TMJD was diagnosed in 40%
of the participants in the test group, 45% white/
brown and 35% black. In addition, in the control
group, 55.3% of the white/brown participants did
not present with TMJD, but in the test group, only
15.0%. It should be noted that the 2 clinical cases
of severe TMJD were diagnosed in 10% of the
black participants in the test group (Tables 3 & 4).

Discussion
Epidemiological surveys have shown that
40–75% of the population have at least one sign
of TMJD, and 33% at least one symptom, such
as face or TMJ pain. In the present study, mild
TMJD had a higher occurrence among participants in the control group (42.5%/34) than in the
test group (37.5%/15). These results corroborate
those of Al-Mobeeriek, who also study the TMJ
condition in psychiatric patients and concluded
that bruxism and tooth clenching were the most
common parafunctions in both groups (34.5%
in the control group and 27.0% in the test group).12
It is also worth mentioning the review article
by Araújo et al., which calls attention to the decisive role of the adverse effects of psychotropic
drugs on the onset of TMJD, associated with
constant headache, reported by people with
schizophrenia, and the difficulty in diagnosing
50 Volume 4 | Issue 2/2018

and treating TMJD in schizophrenic patients
who use psychoactive drugs that may cause
extrapyramidal effects, and recommends a careful evaluation when such patients complain of
orofacial pain.13 Given the impossibility of suspending the use of medications that keep the
symptoms of schizophrenia under control, the
monitoring of these patients, including occasional evaluations of the orofacial region during
dental appointments, is fundamental.
TMJD has already been analyzed in schizophrenic patients, such as in the case–control
study carried out by Velasco-Ortega et al., in
which 32% of schizophrenics presented with
symptoms of TMJD; 24% reported articular
clicks on opening and closing of the mouth; and
8%, abnormal displacement of the mandible
when opening the mouth.14 Among the control
group, only 8% reported cracking of the TMJ. The
authors concluded that schizophrenic patients
are an at-risk population for TMJD because they
present a higher prevalence and severity of TMJD
than do normal individuals. In addition, Gurbuz
et al. pointed to a high prevalence of TMJD in
schizophrenics, with an additional record of
severe tooth wear and bruxism.15 These results
are in line with those obtained in the present
study, which included 31 schizophrenics among
the 40 participants in the test group.
In investigating the most prevalent oral
lesions in psychiatric patients, Moralez-Chaves
et al. observed that 36.92% presented with
noises of the TMJ and 10.76% had muscular
pain. 5 The authors emphasized the need to
implement speciﬁc preventive and educational
oral health programs for these patients.
Clinical cases of severe TMJD were observed
in 2 psychiatric patients, who were older than
35 years and of the black ethnic group and had
an educational level of less than 9 years. One
was a man with a monthly income greater than
the minimum wage and the other a woman with
a monthly income of less than the minimum
wage in force at the time. The impact of mental
disorder and daily use of APs on the onset of
TMJD is evident because only 17. 5% of the
psychiatric patients did not present with TMJ

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Table 3

Test group
Mild

Age

Ethnic group
*P = 0.025

Education

Individual monthly
income

Severe

Absent

Number

%

Number

%

Number

%

Number

%

Male

7

35.0

9

45.0

1

5.0

3

15.0

Female

8

40.0

7

35.0

1

5.0

4

20.0

Total

15

37.5

16

40.0

2

5.0

7

17.5

18–34

4

44.4

3

33.3

–

–

2

22.2

≥ 35

11

35.5

13

41.9

2

6.5

5

16.1

Total

15

37.5

16

40.0

2

5.0

7

17.5

White/brown

8

40.0

9

45.0

–

–

3

15.0

Black

7

35.0

7

35.0

2

10.0

4

20.0

Total

15

37.5

16

40.0

2

5.0

7

17.5

≥ 9 years

5

50.0

3

30.0

–

–

2

20.0

< 9 years

10

33.3

13

43.3

2

6.7

5

16.7

Total

15

37.5

16

40.0

2

5.0

7

17.5

≤ minimum wage

13

40.6

12

37.5

1

3.1

6

18.8

> minimum wage

2

25.0

4

50.0

1

12.5

1

12.5

No income

–

–

–

–

–

–

–

–

Total

15

37.5

16

40.0

2

5.0

7

17.5

TMJD Variable
Sex

Moderate

* Pearson chi-square (P < 0.0010).

impairment, whereas TMJD was found in 82.5%
of the participants of the test group in its different degrees of severity, indicating the need for
longitudinal follow-up of these individuals, with
a view to improving their quality of life.
The IAF can be used for the screening of
patients for TMJD, since it has acceptable measurement properties, especially concerning
internal consistency and reproducibility. However, it is a screening questionnaire, not a diagnostic.16 It should be remembered that this index
characterizes only the presence of symptoms
and not clinical signs of TMJD.17
Fonseca was concerned with the development of an anamnestic index for evaluation of
TMJD adapted to the Brazilian population that
was easy to understand and apply.11 The simplicity of this index favors its use in epidemiological
studies. However, it has not yet been completely
validated and does not offer a TMJD diagnostic
classiﬁcation; the data obtained with this index
are therefore restricted to the classiﬁcation of
severity of TMJD. Another limitation is its scoring
system, since if 3 affirmative answers are given
to the questions about headache, cervical pain
and perceived emotional tension, the respondent
will be classiﬁed as having mild TMJD. However,
these same symptoms may occur in isolation,
with no association with TMJD.18
In this study, in the group with mental and
behavioral disorders (including schizophrenics),

17.5% had no TMJD, 5.0% were diagnosed with
severe TMJD, 40.0% moderate TMJD and 37.5%

mild TMJD regardless of the diagnosed mental
illness. Possibly the subjectivity of the index
used to assess the severity of TMJD may have
induced these results; however, few studies have
evaluated the presence of TMJD in patients with
mental and behavioral disorders who are users
of typical APs.
Side effects from the use of typical APs are
associated with effects on central nervous
system transmission sites and receptors and
appear in relation to dose and potency levels of
the drugs. Patient characteristics, including sex,
age and comorbidity, may make patients more
or less susceptible to certain side effects of APs.
Side effects inﬂuence the patient’s quality of life
and affect compliance regarding medications.19
Few studies have evaluated the presence of
TMJD in schizophrenic users of typical APs.
The importance of psychiatric disorders
associated with TMJD has been reported in the
literature, showing a relationship in the clinical
appearance, prognosis and treatment of TMJD
with psychosocial factors, such as stress, anxiety and depression. The literature states that
emotional aspects play an important role in the
etiology and symptomatic evolution of TMJD,
contributing to the onset or perpetuation of the
disorder by increasing the muscular activity and
tension of the facial muscles. In addition,

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Table 3
Absolute and relative values
of the test group according
to the association between the
sociodemographic variables
and the severity levels
of temporomandibular
dysfunction.

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Table 4

Control group
Mild

Age

Ethnic group
*P = 0.025

Education

Individual monthly
income

Severe

Absent

Number

%

Number

%

Number

%

Number

%

Male

12

30.0

5

12.5

–

–

23

57.5

Female

22

55.0

5

12.5

–

–

13

32.5

Total

34

42.5

10

12.5

–

–

36

45.0

18–34

9

40.9

4

18.2

–

–

9

40.9

≥ 35

25

43.2

6

10.3

–

–

27

46.5

Total

34

42.5

10

12.5

–

–

36

45.0

White/brown

18

38.3

3

6.4

–

–

26

55.3

Black

16

50.0

7

21.9

–

–

9

28.1

Not declared

–

–

–

–

–

–

1

100.0

Total

34

42.5

10

12.5

–

–

36

45.0

≥ 9 years

29

43.3

10

14.9

–

–

28

41.8

< 9 years

5

38.5

–

–

–

–

8

61.5

Total

34

42.5

10

12.5

–

–

36

45.0

≤ minimum wage

20

45.5

9

20.5

–

–

15

34.1

> minimum wage

13

39.4

1

3.0

–

–

19

57.6

No income

1

1.2

–

–

–

–

2

2.5

Total

34

42.5

10

12.5

–

–

36

45.0

TMJD Variable
Sex

Moderate

* Pearson chi-square (P < 0.0010).

Table 4
Absolute and relative values of
the control group according
to the association between the
sociodemographic variables
and the severity levels of
temporomandibular
dysfunction.

cognitive factors suggest an inﬂuence on the
individual’s response to pain, behavioral factors
determine the patient’s attitude, and emotional
tension promotes the onset or aggravation of
clenching and bruxism. In this sense, studies
indicate that anxiety and depression lead to
exacerbation of symptoms and modify perception to pain.10
Delays in the diagnosis of TMJD and incorrect treatment contribute to the onset and perpetuation of pain. However, successful treatment depends on the identiﬁcation and control
of etiological factors and usually requires the
efforts of a multidisciplinary team, associating
dental approaches with those of other areas,
such as those that use different physical, pharmacological or behavioral therapies.10
There are few reports of published cases of
TMJ dislocation due to the use of antipsychotic
medication, which is usually associated with the
use of haloperidol and less associated with drugs
such as risperidone and amisulpride; however,
Karthik and Prabhu reported a case of oromandibular dystonia with displacement of the TMJ
in a psychotic patient treated with oral risperidone and amisulpride.9
The prevalence of TMJD in schizophrenics
was also the focus of a case–control study conducted by Gurbuz et al. in Istanbul, Turkey, in
which 339 schizophrenics and 107 healthy adults
52 Volume 4 | Issue 2/2018

were selected.15 The signs and symptoms of
TMJD were analyzed using the Diagnostic
Criteria for Research on Temporomandibular
Disorders and the results pointed to a high
prevalence of TMJD in schizophrenic patients
(284/339; 83.7%), characterized mainly by pain
on palpation and articular cracklings.
Al-Mobeeriek assessed 100 psychiatric
patients regularly attending a clinic in Saudi
Arabia and compared the results obtained with
those of 84 psychologically normal volunteers.12
Muscular pain, TMJ crackling, limitation of opening of the mouth, bruxism and harmful habits,
such as nail biting and chewing of the lips and
cheeks, were the criteria analyzed in both groups
that composed the sample. According to the
results, the oral health status of psychiatric
patients was worse than that of healthy
individuals, and those with special needs are more
likely to have oral disorders. This study observed
the prevalence of pain sensitivity in the masticatory muscles detected in 37.0% and 22.6% of the
case and control groups, respectively, with temporal muscular pain present in 50.0% of the psychiatric patients and in 44.1% of the healthy volunteers. Cracking was present in 25.0% of the
patients in the case group and in 27.4% of the
control group, and only 1 psychiatric patient
presented with limitation of mouth opening.
Bruxism and tooth clenching were the most

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common parafunctions in both groups (34.5% in
the control group and 27.0% in the case group).
In Latin America, a cross-sectional study was
carried out to determine the most prevalent oral
lesions in 65 hospitalized psychiatric patients at
an institution in Caracas, Venezuela. The presence
of TMJD was described, and 36.92% of the participants reported joint sounds and 10.76%
reported muscular pain, particularly when the
temporal muscle was palpated. Among the most
prevalent parafunctional habits, the authors cited
bruxism, nail biting and cheek chewing, leading to
the conclusion that, in these patients, mouth
changes are more often diagnosed than in mentally healthy individuals, and they pointed to the
need for the implementation of oral health programs, with the commitment of the entire multidisciplinary team involved in mental health care.5

Conclusion
In this study, it was possible to observe the role
of the adverse effects of typical APs in the onset
of TMJD among patients with mental and behavioral disorders, thus justifying the monitoring of
these patients through dental consultations. The
identiﬁcation of possible signs and symptoms of
TMJD represents an important resource for the
early diagnosis of this dysfunction. In this context, the use of indexes has been widely reported
in the literature, especially when validated and
easy to apply and interpret, and with a view to
standardization for data comparison. The IAF
can be used in the screening of patients for
TMJD, since it has easy application and interpretation; however, owing to its subjective nature,
it requires more accurate examination.

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[The orofacials myofunctional disorders
in the dentistry publication: critical
review].
→ Revev Dental Press Ortodon Ortop
Facial.
2005 Jul–Aug;10(4):134– 142.
8.
Benevides SD. Determinação do padrão
da amplitude dos movimentos
mandibulares em escolares de 8 a 12
anos [doctoral thesis].
→ [Salvador]: Universidade Federal da
Bahia, Instituto de Ciências e Saúde;
2013: 132.
9.
Karthik MS, Prabhu N. Temporomandibular joint dislocation due to atypical
antipsychotic-induced acute dystonia: a
case report.
→ Ther Adv Psychopharmacol.
2014 Dec;4(6):282–284.
10.
Ferreira KD, Guimarães JP, Batista CH,
Júnior AM, Ferreira LA. Fatores
psicológicos relacionados à sintomatologia crônica das desordens ttemporomandibulares—revisão de literaturea [Related
psychological factors in chronic
temporomandibular disorder—literature
review].
→ Rev Fac Odontol Univ Passo Fundo.
2009 Sep–Dec;14(3):262–267.

11.
Fonseca, DM. et al. Diagnóstico pela
anamnese da disfunção craniomandibular.
→ Rev. Gauch. Odontol.
1994 Jan/Feb; 42(1): 23-28.
12.
Al-Mobeeriek A. Oral health status
among psychiatric patients in Riyadh,
Saudi Arabia.
→ West Indian Med J.
2012 Aug;61(5):549–554.
13.
Araújo AN, Nascimento MA, Sena EP,
Baptista AF. Temporomandibular
disorders in patients with schizophrenia
using antipsychotic agents: a discussion
paper.
→ Drug Healthc Patient Saf.
2014 Mar; 10;(6): 21–27. doi: 10.2147/
DHPS.S57172.
14.
Velasco-Ortega E, Guil LM, Ponferrada
CV, Soteras RM, Egea JJ. Temporomandibular disorders among schizophrenic patients. A case-control study.
→ Med Oral Patol Oral Cir Bucal.
2005 Aug–Oct;10(4):315–22.

17.
Chaves TC, Costa D, Grossi DB, Bertolli F.
Avaliação anamnésica de sintomas de
disfunção temporomandibular em
crianças asmáticas. [The anamnestic
evaluation of temporomandibular
dysfunction symptoms in asthmatic
children].
→ Fisiot e Pesq.
2005 Jan-Apr;11(1):19–26..
18.
Chaves TC, Oliveira AS, Grossi DB.
Principais instrumentos para avaliação da
disfunção temporomandibular, parte I:
índices e questionários; uma contribuição
para a prática clínica e de pesquisa.
[Main instruments for assessing
temporomandibular disorders, part I:
indices and questionnaires; a contribution
to clinicians and researchers].
→ Fisiot e Pesq.
2008 Mar;15(1):92–100.
19.
George W, Arana MD. An overview
of side effects caused by typical
antipsychotics.
→ J Clin Psychiatry.
2000; 61 (Suppl 8):5–11.

15.
Gurbuz O, Alatas G, Kurt E. Prevalence
of temporomandibular disorder signs
in patients with schizophrenia.
→ J Oral Rehabil.
2009 Dec; 36(12): 864–71.
16.
Pedrosa AS. Propriedades de medida do
Índice Anamnésico de Fonseca :
Universidade Cidade de São Paulo; 2011:
62 http://arquivos.cruzeirodosuleducacional.edu.br/principal/old/mestrado_
ﬁsioterapia/pdf/dissertacao_alexsandra_
de_souza_pedrosa.pdf

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 2/2018 53

[54] => JOSR_2_2018_web.pdf

Industry news

Planmeca introduces new crown
jewel of intra-oral scanning
HELSINKI, Finland: According to Planmeca, one of the largest dental equipment manufacturers,
with products distributed in over 120 countries worldwide, its new Emerald intra-oral scanner has
set the bar for capturing digital impressions and “represents the highest level of scanning available
in the world today”. Planmeca Emerald has been designed with effective usability in mind and
provides accuracy and speed in all situations, the Finnish company said.

Planmeca Emerald’s seamless, autoclavable and
exchangeable tips make infection control
measures simple and efficient. The scanner’s
two buttons allow it to be operated without
touching a mouse or keyboard, and it can even
be controlled from a foot pedal when connected
to a dental unit. The scanner’s plug-and-play
capability allows it to be effortlessly shared
between different rooms and laptops. Owing to
its small size and light weight, the scanner
provides superior control and is comfortable for
patients, the company said.

Planmeca Emerald is a
lightweight, ergonomically
designed intra-oral
scanner that delivers images
with accuracy and detail.

According to Planmeca, the scanner has the
ﬂexibility to support various workﬂows. It can
be used for a wide range of treatment options
and offers beneﬁts across several disciplines,
such as implantology, orthodontics, prosthodontics and maxillofacial surgery. With open
export and import options, regular updates and
constant new features becoming available, the
company continues to evolve and improve the
scanner further. By using a multicolour laserbased system, Planmeca Emerald produces
images with a vibrant colour palette for realistic
digital impressions that allow dentists to
distinguish between hard and soft tissue.
The Planmeca Emerald scanner is part of the
Planmeca FIT chairside CAD/CAM system that
integrates the entire chairside restorative
workﬂow.

54 Volume 4 | Issue 2/2018

Journal of
Oral Science & Rehabilitation

[55] => JOSR_2_2018_web.pdf

register for

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[56] => JOSR_2_2018_web.pdf

Guidelines for authors

Authors must adhere
to the following guidelines
Informed consent

It is preferred that there be no more than six authors.
If more authors have participated in the study, the
Patients have a right to privacy that should not be violated without informed consent. contribution of each author must be disclosed at the
Identifying information, including patients’ names, initials or hospital numbers, should end of the document.
not be provided in the manuscript or visual material unless the information is essential
Title
for scientiﬁc purposes and the patient (or parent or guardian) has given written informed
consent for publication. Informed consent for this purpose requires that an identifiable
patient be shown the manuscript to be published. Authors should disclose to these The title should not exceed 35 characters. Capitalize
patients whether any potential identifiable material might be available via the Internet only the ﬁrst word and proper nouns in the title. Please
as well as in print after publication. Nonessential identifying details should be omitted. include a running title as well.
Informed consent should be obtained if there is any doubt that anonymity can be mainAuthor information
tained. For example, masking the eye region in photographs of patients is inadequate
protection of anonymity. If identifying characteristics are altered to protect anonymity,
authors should provide assurance that alterations do not distort scientiﬁc meaning. The following information must be included for each
When informed consent has been obtained, it should be indicated in the manuscript. author:
– Full author name(s)
– Full afﬁliation (department, faculty, institution,
town, country).

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

For the corresponding author, the following information should be included in addition:
– Full mailing address
– Email address.
Abstract and keywords

The manuscript must contain an abstract and a minimum of 3, maximum of 6 keywords. The abstract
should be self-contained, 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. For case
reports, the sections should be background, case
presentation, conclusion and keywords.
Structure of the main text

The body of the manuscript must be structured
as follows:

Preparing the manuscript text
– Introduction (no subheadings)
– Materials and methods
– Results
The manuscript must be written in U.S. English. The – Discussion
main body of the text, excluding the title page, ab- – Conclusion
stract and list of captions, but including the references, may be a maximum of 4,000 words. ExcepCompeting interests
tions may be allowed with prior approval from the
publisher.
Authors are required to declare any competing ﬁnancial
or other interests regarding the article submitted. Such
Authors will have the opportunity to add more infor- competing interests are to be stated at the end of manmation regarding their article, as well as post videos, uscript before the references. If no competing interests
present a webinar and blog on the DT Science web- are declared, the following will be stated: “The authors
site.
declare that they have no competing interests.”
General

56 Volume 4 | Issue 2/2018

Journal of
Oral Science & Rehabilitation

[57] => JOSR_2_2018_web.pdf

Guidelines for authors

gether, then use lowercase letters to designate these
in a group (e.g., “Figs. 2a–c”).

Acknowledgments

Acknowledgments (if any) should be brief and included at the end of the manuscript before the refer- Place the references to the images in your article
wherever they are appropriate, whether in the midences, and may include supporting grants.
dle or at the end of a sentence. Provide a caption for
each image at the end of your article.
References
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.

Requirements for tables

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
The reference list must be numbered and the refer- descriptive caption, and if numerical measurements
ences provided in order of appearance. For the refer- are given the units should be included in the column
ence list, the journal follows the citation style stipu- headings.
lated in Citing medicine: the NLM style guide for auSupplements/supporting material
thors, editors, and publishers. The guidelines may be
viewed and downloaded free of charge at
DT Science allows an unlimited amount of supporting material (such as datasets, videos or other addiwww.ncbi.nlm.nih.gov/books/NBK7256/
tional information) to be uploaded. This material
The reference list may not exceed 50 references.
should be presented succinctly (in English). The author bears full responsibility for the content. Color,
List of captions
animated multimedia presentations, videos and so
Please provide the captions for all visual material at on are welcome and published at no additional cost
to the author or reader. Please refer briefly to such
the end of the manuscript.
material in the manuscript where appropriate (e.g.,
as an endnote).
Abbreviations
Abbreviations should be used sparingly and deﬁned
when ﬁrst used. The abstract and the main manuscript text should be regarded as separate documents
in this regard.
Typography

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

Submit your research and
clinical articles to
Dr. Miguel Peñarrocha Diago at
penarrochamiguel@gmail.com

For all other requests,
contact

Preparing the visual material
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 to-

Journal of
Oral Science & Rehabilitation

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 4 | Issue 2/2018

57

[58] => JOSR_2_2018_web.pdf

Imprint: About the publisher

Publishing team

Editorial board

Publisher/President/CEO

Editors-in-Chief

Torsten R. Oemus
t.oemus@dental-tribune.com
Managing Editor
Nathalie Schüller
n.schueller@dental-tribune.com

Miguel Peñarrocha Diago, Valencia, Spain
Daniele Botticelli, Rimini, Italy
Associate editors
Luigi Canullo, Rome, Italy
David Peñarrocha Oltra, Valencia, Spain

Concept & design

International office
Dental Tribune International
Holbeinstr. 29
04229 Leipzig
Germany

Rhowerk
www.rhowerk.de
C h i e f Te c h n o l o g y O f f i c e r
Serban Veres
serbanveres@gmail.com
Copy editor

T +49 341 4847 4302
F +49 341 4847 4173

Sabrina Raaff
Ann-Katrin Paulick

info@dental-tribune.com
www.dental-tribune.com

International administration

Scientific advisers
Pablo Galindo Moreno, Granada, Spain
Georgios Romanos, Stony Brook, N.Y., U.S.
Giovanni Serino, Borås, Sweden
Statistical advisers
Marco Tallarico, Sassari, Italy
Francesco Tessarolo, Mattarello, Italy
Executive board

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

Junior Business
Development & Marketing
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Marketing & Sales Services
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Accounting Services
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k.hamatschek@dental-tribune.com
Manuela Hunger
m.hunger@dental-tribune.com
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
58 Volume 4 | Issue 2/2018

Journal of
Oral Science & Rehabilitation

Marcus Abboud, Stony Brook, N.Y., U.S.
Marco Álvarez, Mexico City, Mexico
Conrado Aparicio, Minneapolis, Minn., U.S.
Karol Alí Apaza Alccayhuaman, Rimini, Italy
Shunsuke Baba, Osaka, Japan
Antonio Barone, Geneva, Switzerland
Franco Bengazi, Brescia, Italy
José Luis Calvo Guirado, Murcia, Spain
Andrea Edoardo Bianchi, Milan, Italy
Manuel Bravo Pérez, Granada, Spain
Eriberto Bressan, Padua, Italy
Marco Caneva, Trieste, Italy
Ugo Covani, Pisa and Camaiore, Italy
Juan Carlos De Vicente Rodríguez, Oviedo, Spain
Rafael Arcesio Delgado Ruiz, Stony Brook, N.Y., U.S.
Giacomo Derchi, La Spezia, Italy
Stefan Fickl, Würzburg, Germany
Joseph Fiorellini, Philadelphia, Pa., U.S.
Carlo Fornaini, Fiorenzuola d'Arda, Italy
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
Francesco Guido Mangano, Milan, Italy
Aleksa Markovic, Belgrade, Serbia
José Eduardo Maté Sánchez de Val, Murcia, Spain
Silvio Meloni, Sassari, Italy
Eitan Mijiritsky, Tel Aviv, Israel
Alberto Monje, Ann Arbor, Mich., U.S.
Yasushi Nakajima, Osaka, Japan
Ulf Nannmark, Gothenburg, Sweden
Wilson Roberto Poi, Araçatuba, Brazil
Rosario Prisco, Foggia, Italy
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, Bern, 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

[59] => JOSR_2_2018_web.pdf

YOUR PATIENTS ARE NOT STATUES,
AND THAT’S OK.
Patient movement is the number one contributor to
compromised image quality. Our new Planmeca CALM™
corrective algorithm will allow you to eliminate movement
artefacts from CBCT images and succeed every time.

Without Planmeca CALM™

With Planmeca CALM™

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for all Planmeca
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Movement artefact correction for CBCT images
Planmeca Oy
y Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com

[60] => JOSR_2_2018_web.pdf

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for optimal seal

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and growth

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