Journal of Oral Science & Rehabilitation No. 2, 2019
Cover
/ Editorial
/ Content
/ About the Journal of Oral Science & Rehabilitation & About Dental Tribune Science
/ Subcutaneous emphysema after a direct sinus lift: A case report
/ Digital bone augmentation in posterior mandibles: A retrospective CBCT study and proposal of a 2-step bone augmentation protocol
/ Autotransplantation: Salvaging an odontoma-associated unerupted anterior tooth
/ Evaluation of the muscular activity and myodynamic balance in children with physiological dental occlusion
/ Guidelines for authors
/ Imprint
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[1] =>
Volume 5 | Issue 2/2019
ISSN 2365 - 6891 (ONLINE)
Journal of
www.dtscience.com
Oral Science & Rehabilitation
Journal for periodontology, implant dentistry,
dental prosthodontics and maxillofacial surgery
[2] =>
© MIS Implants Technologies Ltd. All rights reserved.
Kapitelüberschriften
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in soft tissue preservation and growth as well as an array of restorative benefits. Learn
Journal
of Oral
& Rehabilitation | Volume 5 – Issue 2/2019
more about the SEVEN
implant system
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MIS at: www.mis-implants.com
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[3] =>
Editorial
Dentistry, quo vadis ?
As a professional who has devoted my life to dentistry,
treating patients, teaching at a university and contributing to my branch of science, I am growing older,
gaining experience and analyzing things from different
perspectives. After reflecting on and evaluating my
more than 25 years of clinical practice, my role as a
teacher and mentor to many students, and my current
knowledge, I wonder where to from here.
The knowledge in dentistry is changing rapidly based
on different premises. The academic institution has
made it clear that randomized clinical trials and metaanalyses are at the top of the pyramid of scientific
knowledge. There are some journals that rarely accept
a manuscript that does not have in its title the magic
words “randomized clinical trial”; yet, there are thousands of systematic reviews and meta-analyses on
any meaningless aspect of the literature, meta-analysis
based only on those randomized clinical trials. Sometimes, journals publish some meta-analyses based
only on one or two manuscripts, which is simply a repetition of the same conclusion of the manuscript. Interestingly, there is even a coincidence in the authorship
of both manuscripts, a kind of misconduct in science.
When analyzing the bibliometric aspects of our
science, in the context of science, dentistry is almost
nothing in comparison with other disciplines; it is like a
small star in the Milky Way. However, we are trying to
resemble the disciplines of older brothers, forgetting
the strength of our own science. As dentists, we are
required to contribute the best for patients, reinforcing
clinical aspects, based on knowledge and evidence.
We are health care providers. Our editors, journals and
reviewers, and we ourselves must become aware of
this, support deeper clinical research that undoubtedly
contributes to better feedback in all fields for our patients and avoid many of those manuscripts that are
only aimed at greater impact factors, h-indexes or citations, increasing the ego and visibility of some authors
and institutions, with no benefit for the real readers of
our journals and the final destination of our research:
our patients.
As a professor, as a researcher, assuming my share
of mea culpa, I begin to be fed up with diving into the
literature looking for important manuscripts that bring
light and knowledge to our community, but remaining
unsatisfied. I begin to wonder, dentistry, quo vadis?
Dr. Pablo Galindo Moreno
Associate editor and scientific adviser
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
3
[4] =>
Contents
Contents
3
Editorial
6
About the Journal of Oral Science & Rehabilitation
8
María Sevilla Heras et al.
14
Farah Asa’ad et al.
26
Min Jim Lim et al.
34
Nabi Nabiev et al.
44
Guidelines for authors
46
Imprint — About the publisher
4
Dr. Pablo Galindo Moreno
Subcutaneous emphysema after a direct sinus lift: A case report
Digital bone augmentation in posterior mandibles: A retrospective CBCT study
and proposal of a 2-step bone augmentation protocol
Autotransplantation: Salvaging an odontoma-associated unerupted anterior tooth
Evaluation of the muscular activity and myodynamic balance in children
with physiological dental occlusion
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[5] =>
Kapitelüberschriften
PRINT
EVENTS
SERVICES
EDUCATION
DIGITAL
Dental Tribune International
The World's
Dental Marketplace
www.dental-tribune.com
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
5
[6] =>
About
About
the Journal of Oral Science & Rehabilitation
The aim of the Journal of Oral Science & Rehabilitation
is to promote rapid communication of scientific information between academia, industry and dental practitioners, thereby influencing the decision-making in
clinical practice on an international level.
The Journal of Oral Science & Rehabilitation publishes
original and high quality 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 openaccess 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
6
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[7] =>
About
Benefits of publishing in the journal
for authors
There are numerous advantages of publishing in the Journal of Oral Science & Rehabilitation:
• Accepted papers are published in print and
as e-papers on www.dtscience.com;
abstracts are published on www.dental-tribune.com.
• Authors’ work is granted exposure to a wide
readership, ensuring increased impact of their
research through open-access publishing
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• Authors have the opportunity to present and
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and articles published on both www.dtscience.com
and www.dental-tribune.com.
• Authors can also post videos relating to
their research, present a webinar and blog
on www.dtscience.com.
Subscription price
€50.00 per issue, including VAT and shipping costs.
Information for subscribers
The journal is published quarterly. Each issue is published as both a print version
and an e-paper on www.dtscience.com.
Terms of delivery
The subscription price includes delivery of print journals to the recipient’s address.
The terms of delivery are delivered at place (DAP); the recipient is responsible for
any import duty or taxes.
Copyright © Dental Tribune International GmbH. Published by Dental Tribune International GmbH. All rights
reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means
without prior permission in writing from the copyright holder.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
7
[8] =>
Subcutaneous emphysema after a direct sinus lift
Subcutaneous emphysema after a
direct sinus lift: A case report
María Sevilla Heras,a
Luis Martorell Calatayud,a
Regino Zaragozí Alonsoa &
Miguel Peñarrocha Diagoa
a
Department of Stomatology, Faculty of Medicine and Dentistry,
University of Valencia, Valencia, Spain
Department of Oral Surgery and Implantology
Corresponding author:
Dr. Luis Martorell Calatayud
Universidad de Valencia
Facultad de Medicina y Odontología
Clínica Odontológic. Cirugía bucal
C/ Gascó Oliag, 1
46021 Valencia
Spain
luismartorell@hotmail.com
How to cite this article: Sevilla Heras M, Martorell
Calatayud L, Zaragozí Alonso R, Peñarrocha Diago
M. Subcutaneous emphysema after a direct sinus
lift: A case report. J Oral Science Rehabilitation. 2019
Jun;5(2):8–13.
Materials and methods
A 52-year-old patient underwent a maxillary direct sinus
lift for the future placement of implants in the posterior
area. A few hours after the surgery, the patient repeatedly sneezed with his mouth closed 3 times, immediately causing a large swelling in the left periorbital area
that prevented him from opening the eye. After clinical
and radiographic examination, it was determined that
it was a subcutaneous emphysema. The prescribed
treatment was antibiotics.
Conclusion
Subcutaneous emphysema is a benign and usually
self-limited entity, which usually resolves spontaneously. Most authors agree on the use of turbines as the
most frequent etiology. Other reasons, however, have
also been reported in the literature, such as endodontic treatment and the use of dental lasers. The main
clinical manifestations that aided us in establishing
a correct differential diagnosis were swelling without
redness, edema and crepitating palpation of the soft
tissue. In general, patients do not report pain, but at
worst a slight discomfort due to swelling.
Keywords
Subcutaneous emphysema; periorbital edema; orbital
emphysema; complications; sinus floor elevation.
Abstract
Introduction
Objective
Subcutaneous oral emphysema is defined as penetration of pressurized air into the tissue spaces. One
possible means of air entry is through the bone window
made during a direct sinus lift. There are only 3 cases
published in the literature of subcutaneous emphysema with this etiology. It is important that the dentist
carefully instruct the patient about the post-surgical
protocol that must be carried out to reduce the risk of
this complication.
Subcutaneous emphysema is defined as the penetration of air pressure into tissue spaces.1–8 It is a complication that has been described in the literature for
many years. In 1995, Heyman and Babayof reviewed
the literature from 1960 to 1993 on emphysematous
complications in dental treatment.1
8
Subcutaneous emphysema does not occur regularly,
but it is important to control to avoid complications
such as infections that can be harmful to the patient.9
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[9] =>
Subcutaneous emphysema after a direct sinus lift
Fig. 1
The condition is usually the result of treatment with
high-speed surgical drills and compressed air syringes during restorative and endodontic procedures.5
However, in the present case, periorbital edema was
observed after several hours of a sinus floor elevation,
which makes this case report interesting. There are not
many cases reported in the literature about this etiology, which is mostly related to post-surgical maneuvers of the patient (sneezing while keeping the mouth
closed, blowing the nose, playing wind instruments).10
The objective of this clinical case is to demonstrate to
oral and maxillofacial surgeons the possibility of orbital
and periorbital emphysema after an intervention in the
maxillary sinus, as well as the procedure to follow in
the case of this complication.
Study design and ethical aspects
The present study is a case report. The patient was
willing and fully capable of complying with the clinical
procedures, and a written informed consent was obtained 7 days before the initiation of treatment.
Case report
The patient was 52 years old and a nonsmoker. He
attended the periodontics department (University of
Valencia, Valencia, Spain) for checks and controls
periodically. The Department of Oral Surgery and Implantology, University of Valencia, Valencia, Spain, requested restoration of his missing teeth with implants.
The third and second molars had been extracted
about 20 months before the observation. The patient
was willing to have the right maxillary posterior area
rehabilitated with a fixed prosthesis (Figs. 1 & 2).
The oral rehabilitation plan called for the placement
of an implant 10 mm long and 4 mm wide distal to the
maxillary second left premolar. In the right maxilla, an
atraumatic sinus lift was sufficient.
The residual height of the bone in the left maxilla
was less than 5 mm, which was evaluated by cone
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
9
[10] =>
Subcutaneous emphysema after a direct sinus lift
Fig. 2
beam computed tomography. As there was not enough
bone height to place an implant in a standard way, it
was decided to proceed with a traumatic sinus lift. The
patient did not present any contraindication to or systemic disease that would contraindicate the procedure.
Surgical procedure
For the intervention of vertical increase of bone in the
maxillary sinus, antibiotic pre-medication was prescribed: amoxicillin (500 mg, 1 tablet every 8 h for 7
days), starting 2 days before. It was also recommended
to take ibuprofen (600 mg, 1 tablet) 1 h before surgery.
Local anesthesia was administered by infiltration with
articaine plus 1:100,000 epinephrine (Ultracain, 40 mg;
Normon; 3 cartridges of 1.8 mL per cartridge).
A crestal incision was made in the edentulous area,
followed by a vertical incision, mesial to the second
premolar, surpassing the mucogingival line. A mucoperiosteal flap was raised to full thickness to visualize
the lateral wall of the maxillary sinus. The extraction
of the first molar was performed prior to access to the
maxillary sinus.
The access to the maxillary sinus was performed
using the lateral access technique. The window had
dimensions of 10 × 8 mm, made first with a handpiece
and tungsten carbide drill and then with a piezoelectric instrument (Piezomed, W&H). Then, to elevate the
sinus membrane, angulated manual instruments were
10
used in direct contact with the bone (sinus membrane
separators 718-EN2, MC-1 and MC-2, Bontempi).
The Valsalva maneuver to check whether the membrane had suffered any perforation was positive. We
thus placed a small piece of membrane that covered it
completely. Then we filled the whole sinus cavity with
a bovine-derived xenograft (Bio-Oss, 0.25–1.00 mm
granules; Geistlich Biomaterials). The total amount
of xenograft used was 2.5 g. The lateral window was
covered with a 13–25 mm resorbable collagen membrane (Bio-Gide, Geistlich Biomaterials). Seven simple
sutures were performed with Supramid (5/0, circ., nonresorbable; Steinerberg), starting at the angles and
continuing through the crestal and middle incisions. A
periapical radiograph (Fig. 3) and a dental panoramic
tomogram (Fig. 4) were taken at the end of the intervention.
The patient was provided with post-surgical instructions, both verbal and written. The recommendations
included soft and cold food for the first several days,
cold application in the surgical area, no smoking and
avoiding brushing for the first several days, and use of
a 0.12% chlorhexidine rinse (Perio•Aid, 0.2% chlorhexidine and 0.05% cetylpyridinium chloride; Dentaid) for
1 min, 3 times a day for 10 days. The patient was told
that he could make use of anti-inflammatory therapy
for pain or swelling.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[11] =>
Subcutaneous emphysema after a direct sinus lift
Fig. 3
Fig. 4
Clinical management and resolution of orbital and
periorbital emphysema
Onset and clinical aspect
On the same day of the surgery, 3 h later, the patient
reported a large area of inflammation on the left side of
the face that appeared immediately after 3 continuous
sneezes (Fig. 5). The patient underwent a clinical examination of the affected area. He had no pain and his
sight was unaltered, although the inflammation limited
the opening of the eyelid. The extrinsic musculature of
the eye was not involved. A visit to an ophthalmological specialist was not considered necessary. A control
dental panoramic tomogram was performed and it did
not reveal any alteration in the bone elevation. The
diagnosis of subcutaneous emphysema was explained to the patient. Amoxicillin, 875 mg, and clavulanic acid, 125 mg, 1 tablet every 8 h for 7 days, was
prescribed.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
11
[12] =>
Subcutaneous emphysema after a direct sinus lift
differential diagnosis were swelling without redness
and the crepitating palpation of the soft tissue.12 Few
authors have reported cases related to the eye and
orbital tissue.10–16 Commonly, patients report no pain,
but at worst a slight discomfort due to inflammation.
Fig. 5a
Resolution
By the third day, the reduction of emphysema was
already very noticeable, and the inflammation had decreased, disappearing completely after 7 days. The
resolution of emphysema occurred without any other
complication. The patient did not have an infection or
pain.
Discussion
In the present clinical case, subcutaneous emphysema appeared after powerful sneezing of the patient
after elevation of the maxillary sinus. The objective of
the report of this case is to communicate the signs and
symptoms of subcutaneous emphysema at the level
of the periorbital area, as well as the favorable progress in a few days with good pharmacological management.
Many authors have recorded the complication of
subcutaneous emphysema, especially after dental interventions. Most of them agree that the use of air-operated handpieces for dental extractions is the most
frequent cause.4, 6, 11, 12 However, other reasons have
also been described: preparation for and placement of
crowns,13 endodontic treatment and retreatment, and
the use of the dental laser.7, 14, 15
It is important to make a differential diagnosis
through comparison with other pathologies that
produce an increase in volume, such as an allergic
reaction or a hematoma. Therefore, a detailed clinical history and the correct palpation of the area to
achieve a correct diagnosis is very important. The main
manifestations that aided us in establishing a correct
12
Air can enter the parapharyngeal and retropharyngeal spaces, where accumulation of air can lead to
airway compromise, air embolism and soft-tissue infection. Pneumothorax, optic nerve damage and even
death by air embolism has been reported.1
Prophylactic antibiotics, meticulous observation of
the respiratory tract and monitoring of gas extension
are recommended.1, 17 To prevent secondary infections,
the administration of antibiotics is recommended. In
this case, amoxicillin and clavulanic acid as prescribed
was sufficient for resolution of the case.
Conclusion
The present case report has shown how subcutaneous
emphysema can occur as a result of the sneezing of
the patient after maxillary sinus augmentation. It was
handled correctly with the use of antibiotics and follow-up. Subcutaneous emphysema did not affect the
success of the vertical augmentation procedure.
Competing interests
The authors declare that they have no competing interests.
Legends
Fig. 1 – Preoperative periapical radiograph.
Fig. 2 – Preoperative dental panoramic tomogram.
Fig. 3 – Postoperative periapical radiograph.
Fig. 4 – Postoperative dental panoramic tomogram.
Fig. 5 – Clinical image of subcutaneous emphysema.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[13] =>
Subcutaneous emphysema after a direct sinus lift
References
1. Heyman SN, Babayof I. Emphysematous complications in dentistry, 1960–1993: an illustrative case
and review of the literature. Quintessence Int. 1995
Aug;26(8):535–43.
2. Jawaid MS. Orbital emphysema: nose blowing
leading to a blown orbit.
→ BMJ Case Rep.
2015 Oct 29;2015. pii: bcr2015212554. doi:10.1136/bcr2015-212554.
3. Fleischman D, Davis RM, Lee LB. Subcutaneous
and periorbital emphysema following dental procedure.
→ Ophthalmic Plast Reconstr Surg.
2014 Mar–Apr;30(2):e43–5. doi: 10.1097/IOP.0b013e
318295f982.
4. Romeo U, Galanakis A, Lerario F, Daniele GM,
Tenore G, Palaia G. Subcutaneous emphysema during
third molar surgery: a case report.
→ Braz Dent J.
2011;22(1):83–6.
5. McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema of dental and surgical origin: a literature review.
→ J Oral Maxillofac Surg.
2009 Jun;67(6):1265–8.
6. Tomasetti P, Kuttenberger J, Bassetti R. Distinct subcutaneous emphysema following surgical
wisdom tooth extraction in a patient suffering from
“Gilles de la Tourette syndrome”.
→ J Surg Case Rep.
2015 Jun 14;2015(6). pii: rjv068. doi: 10.1093/jscr/
rjv068.
7. Mitsunaga S, Iwai T, Kitajima H, Yajima Y, Ohya T,
Hirota M, Mitsudo K, Aoki N, Yamashita Y, Omura S,
Tohnai I. Cervicofacial subcutaneous emphysema associated with dental laser treatment.
→ Aust Dent J.
2013 Dec;58(4):424–7.
8. Parkar A, Medhurst C, Irbash M, Philpott C. Periorbital oedema and surgical emphysema, an unusual
complication of a dental procedure: a case report.
→ Cases J.
2009 Sep 1;2:8108. doi: 10.4076/1757-1626-2-8108.
9. Sahoo NK, Singh S, Roy ID, Bhandari A. Early postoperative malignant subcutaneous emphysema: report
and review.
→ J Maxillofac Oral Surg.
2017 Mar;16(1):85–9.
10. Farina R, Zaetta A, Minenna L, Trombelli L. Orbital
and periorbital emphysema following maxillary sinus
floor elevation: a case report and literature review.
→ J Oral Maxillofac Surg.
2016 Nov;74(11):2192.e1–2192.e7. doi: 10.1016/j.
joms.2016.06.186. Epub 2016 Jul 1.
11. Arai I, Aoki T, Yamazaki H, Ota Y, Kaneko A. Pneumomediastinum and subcutaneous emphysema after
dental extraction detected incidentally by regular
medical checkup: a case report.
→ Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2009
Apr;107(4):e33–8.
doi:
10.1016/j.
tripleo.2008.12.019.
12. Tan S, Nikolarakos D. Subcutaneous emphysema
secondary to dental extraction: a case report.
→ Aust Dent J.
2017 Mar;62(1):95–7.
13. Khandelwal V, Agrawal P, Agrawal D, Nayak PA.
Subcutaneous emphysema of periorbital region after
stainless steel crown preparation in a young child.
→ BMJ Case Rep.
2013 May 22;2013. pii: bcr2013009952. doi: 10.1136/
bcr-2013-009952.
14. Al-Qudah A, Amin F, Hassona Y. Periorbital emphysema during endodontic retreatment of an upper central
incisor: a case report.
→ Br Dent J.
2013 Nov 8;215(9):459–61.
15. Imai T, Michizawa M, Arimoto E, Kimoto M, Yura Y.
Cervicofacial subcutaneous emphysema and pneumomediastinum after intraoral laser irradiation.
→ J Oral Maxillofac Surg.
2009 Feb;67(2):428–30.
16. Stacchi C, Sentineri R, Berton F, Lombardi T. Conjunctival chemosis: an uncommon complication after
transcrestal lifting of the sinus floor.
→ Br J Oral Maxillofac Surg.
2016 Nov;54(9):1052–4.
17. Kung JC, Chuang FH, Hsu KJ, Shih YL, Chen CM,
Huang IY. Extensive subcutaneous emphysema after
extraction of a mandibular third molar: a case report.
→ Kaohsiung J Med Sci. 2009 Oct;25(10):562–6.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
13
[14] =>
Atrophic posterior mandibles and virtually designed grafts
Digital bone augmentation in posterior
mandibles: A retrospective CBCT study
and proposal of a 2-step bone augmentation
protocol
Authors:
Farah Asa’ad,a Luca Ferrantino,b
Tiziano Testoric & Dario Consonnid
a
b
c
d
Institute of Odontology, Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden; Department of Biomedical,
Surgical and Dental Sciences, Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
Department of Oral Rehabilitation, Istituto Stomatologico
Italiano, University of Milan, Milan, Italy
Department of Biomedical, Surgical and Dental Sciences,
Unit of Implant Dentistry and Oral Rehabilitation, IRCCS
Galeazzi Institute, University of Milan, Milan, Italy
Epidemiology Unit, Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico, Milan, Italy
Corresponding author:
Dr. Farah Asa’ad
Institute of Odontology
Sahlgrenska Academy
University of Gothenburg
Box 450
SE 405 30 Gothenburg
Sweden
farahasaad83@gmail.com
How to cite this article: Asa’ad F, Ferrantino L, Testori
T, Consonni D. Digital bone augmentation in posterior
mandibles: A retrospective CBCT study and proposal
of a 2-step bone augmentation protocol. J Oral Science
Rehabilitation. 2019 Jun;5(2):14–25.
Abstract
Objective
The objective was to analyze bone resorption patterns
in posterior mandibles and the dimensions of their corresponding digital bone grafts. This could allow the
fabrication of bone grafts with standardized dimensions
14
that can be applied in the majority of clinical cases.
Materials and methods
Cone beam computed tomography scans (n = 120)
were analyzed to evaluate the frequency of Cawood
and Howell (C&H) classes. The most frequent class
needing bone augmentation was virtually regenerated
using specific software. Dimensions of the grafts were
calculated.
Results
Class V was the most frequent atrophic class needing
augmentation in posterior mandibles (20.4%). Severe
atrophic stages were more frequent in females (adjusted P value = 0.001), in older people (adjusted
P value = 0.31) and in the right mandible (adjusted
P value = 0.03). After virtual regeneration of Class V
cases (n = 36), 3 clusters based on the number of
missing teeth were evident. The mean length of
the grafts was 20 mm when 2 teeth were missing
(reference), 23.9 mm in the case of 3 missing teeth
(P < 0.001) and 29.6 mm for 4 missing teeth
(P < 0.001). Height and width were comparable
across the 3 clusters (P-values = 0.39–0.93). The mean
graft volume was 1,469 mm3 in the case of 2 missing
teeth (reference), 1,814 mm3 for 3 missing teeth
(P = 0.001) and 2,177 mm3 for 4 missing teeth
(P < 0.001). These volumes corresponded to those
of soft-tissue expanders, suggesting the possibility
of a 2-step augmentation protocol: soft-tissue
expansion, followed by regeneration with prefabricated grafts of the corresponding volume.
Conclusion
Class V was the most frequent resorption pattern requiring augmentation in posterior mandibles. Virtual
regeneration revealed 3 clusters of grafts, differing
only in length based on the number of missing teeth.
A 2-step augmentation protocol is proposed using
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[15] =>
Atrophic posterior mandibles and virtually designed grafts
soft-tissue expanders and prefabricated grafts with
corresponding volumes. This protocol might be more
applicable in the right mandible, females and older patients.
Keywords
Mandible; alveolar bone grafting; bone graft; cone
beam computed tomography; soft-tissue expansion.
Introduction
To ensure a successful dental implant therapy, the
presence of adequate amounts of vertical and horizontal alveolar bone is fundamental.1 Therefore, horizontal
and/or vertical alveolar bone augmentation procedures
are performed whenever the alveolar bone volume is
inadequate.
Although horizontal and vertical bone augmentation
procedures are both technique-sensitive, the latter is
more challenging and several surgical techniques are
applied, such as vertical guided bone regeneration,
onlay grafting, inlay grafting and distraction osteogenesis.2, 3 As is known, vertical bone augmentation is frequently associated with high rates of complications,
such as soft-tissue dehiscence and subsequent exposure of bone grafts in the oral cavity.4 Consequently,
soft-tissue expansion (STE) has been introduced, to
enhance the quantity and quality of soft tissue prior to
bone augmentation procedures, by using self-inflating
soft-tissue expanders (for a review, see Asa’ad et al.5).
STE facilitates passive closure of the flap, thus decreasing patient morbidity and improving regenerative
outcomes.
With the introduction of solid freeform fabrication
techniques, researchers became interested in developing custom-made bone grafts with complex architectures6 that conform better to more complex defects,
thus increasing the predictability of regenerative outcomes, especially in complex defect areas and in posterior mandibles, as the rehabilitation of this edentulous area with dental implants is very challenging for
clinicians in modern dental practice.7 Such systems
utilize computer-aided design (CAD) and computeraided manufacturing (CAM) technologies to 3-D print
a desired structure based on a CAD file that contains the
already determined graft dimensions.8 In a typical clinical case scenario, CAD models are produced based
on images from computed tomography (CT) scans of a
patient-specific bone defect to develop a custom-made
synthetic graft to regenerate defects with complex
geometry9 (for a review, see Asa’ad et al.10).
Recently in the literature, a case series focused on
the concept of custom-made grafts and minimally invasive surgical procedures for alveolar bone regeneration using subtractive technologies, that is, milling of a
commercially available block using CAD/CAM technologies.11 Nonetheless, creating a customized bone graft
for every clinical case could be of very high cost, mainly
owing to the required armamentarium and setup. In this
regard, providing standardized prefabricated synthetic
bone grafts that can be applied in most clinical case
scenarios with minimal chairside modifications might
be a more cost-effective alternative. This concept was
previously investigated by Metzger et al., who evaluated the topographical anatomy of the human orbital
floor for the production of prefabricated implants on the
basis of data obtained from conventional CT.12
Therefore, the aim of the present retrospective study
was to analyze bone resorption patterns in right and
left posterior mandibles and the corresponding digital
bone grafts, in a single population, to evaluate whether
the grafts could be grouped into distinct clusters. We
also present a preliminary analysis of the severity of
bone resorption and number of missing posterior teeth
in relation to age, sex and mandibular side. We also
propose a 2-step bone augmentation protocol, entailing STE, followed by placement of a prefabricated
bone graft of the corresponding volume.
Materials and methods
CBCT scans and inclusion criteria
An entire database (a total of 300 cone beam computed tomography [CBCT] scans dated from 2011 to
2016) of a private dental practice in Como, Italy, was
accessed during the period of April–June 2016. All
the CBCT scans were generated by the same CBCT
equipment (Planmeca ProMax 3D Max, Planmeca,
Helsinki, Finland) with the following exposure settings:
90 kV and 8 mA or 10 mA for 12 – 15 seconds.
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Atrophic posterior mandibles and virtually designed grafts
After all the scans were screened, only 120 scans
met the inclusion criteria, and thus were selected for
the final analysis. As a routine protocol, all the patients
signed an informed consent form agreeing to the use
of their data for scientific purposes. All patients were
treated according to the principles contained in the
Declaration of Helsinki of 1980 for biomedical research
involving human subjects. Screening of scans and selection were performed by the same investigator (FA).
The final CBCT scans met the following inclusion
criteria:
1. Scans had to be of patients of 35 years of age
or older. The cutoff point for inclusion was set at
35 years of age based on the finding in the literature
that peak bone density is reached by age 35,13 after
which bone density/mass starts to decrease.
2. Scans had to be of patients without any reported
systemic diseases that affect bone (e.g., osteoporosis), as verified from patients’ records.
3. At least 1 side of the posterior mandible had to be
either partially or fully edentulous.
4. The edentulous area had to have at least 2 consecutive posterior missing teeth, 1 of them a molar, as
follows: (i) missing first and second molars (2 teeth);
(ii) missing second premolar and first and second
molars (3 teeth); and (iii) missing first and second
premolars and first and second molars (4 teeth).
5. Alveolar bone resorption had to be physiological after tooth loss/extraction and not related to any trauma or pathologies, as verified from patients’ records.
The CBCT scan exclusion criteria were the following:
1. Patients who reported systemic diseases that would
affect the alveolar bone, for example osteoporosis.
2. History of previous bone grafting procedures, as this
variable affects bone morphology.
3. Sole presence of edentulous maxillary sextants, as
the upper jaw was not the region of interest in this
retrospective study. It must be noted that the posterior mandible was selected as the region of interest because its rehabilitation is considered the most
challenging for clinicians in modern dental practice.7
For the final 120 scans, each included at least 1 side of
the posterior mandible that met the inclusion criteria for
analysis. Afterward, the contralateral mandibular side
was assessed as well. If it met the inclusion criteria, it
was also included in the final analysis, but if not, that
segment was excluded. It must be noted that, in that
case, the segment was excluded from the overall frequency analysis and not the scan. The contralateral
Fig. 1
16
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Atrophic posterior mandibles and virtually designed grafts
Fig. 2a
segment was eliminated from the final analysis if it had
1 of the following characteristics:
1. fully dentate arch (Cawood and Howell Class I);
2. nonconsecutive missing posterior teeth;
3. 1 missing posterior tooth;
4. 2 missing premolars;
5. bounded saddle areas consisting of a missing second premolar and missing first molar (first premolar
and second molar were present); and
6. edentulous area already restored with dental implants.
Analysis of mandibular bone resorption patterns
on CBCT scans
The pattern of the mandibular bone loss was assessed
by the same examiner (FA), using the classification
proposed by Cawood and Howell (C&H).14 This classification system is among the most widely used to categorize edentulous ridges.15 The ridge displays a specific shape during different phases of bone resorption
that can be clearly identified on CBCT scans (Fig. 1).16
The C&H classification divides the posterior mandible
into 6 groups as follows:
1. Class I: dentate;
2. Class II: immediately post-extraction;
3. Class III: well-rounded ridge form,
adequate in height and width;
4. Class IV: knife-edge ridge form,
adequate in height and inadequate in width;
5. Class V: flat ridge form, inadequate in height
and width;
6. Class VI: depressed ridge form with
some basal loss evident.
Frequency analysis of bone resorption patterns was
done using DICOM files imported into OS3D 2.0 software (3DMed, L’Aquila, Italy). Frequency analysis of
bone resorption pattern and number of missing teeth
were compared for age, sex and mandibular side.
Virtual bone regeneration and digital bone grafts
Virtual regeneration with digital bone grafts was performed after the frequency analysis had been completed. This step was only done for the most frequent
C&H class requiring bone augmentation (i.e., the most
frequent class among Classes IV, V and VI).
By means of imaging software (OS3D 2.0), the
digital data were processed to obtain a 3-D image of
the bone loss, and a virtual graft was designed, simulating a real bone grafting procedure (Fig. 2a), as
described by Jacotti et al.17 The software allowed the
determination of the length, height and width of each
graft. The software also verified the intimate adaptation between the virtual graft and the underlying bone
surface. As a guide for the virtual bone regeneration
procedure, the residual bone height above the mandibular canal was measured, and then the virtual graft
height was determined by the ability to accommodate
an implant of a standard height (10 mm) with a 2 mm
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Atrophic posterior mandibles and virtually designed grafts
safety zone above the mandibular canal (Fig. 2b).
Virtual graft width was determined by the ability to accommodate a 3.25 mm diameter dental implant. Virtual
graft length was based on the number of missing consecutive posterior teeth. The 3-D planning software
allowed for virtual dental implant placement, subsequent virtual bone regeneration and verification of the
graft dimensions.
Age
group,
years
Female,
n (%)
Male,
n (%)
Total,
n (%)
< 65
23 (31.5)
21 (44.7)
44 (36.7)
≥ 65
50 (68.5)
26 (55.3)
76 (63.3)
Total
73 (100)
47 (100)
120 (100)
Table 1: Age and sex distribution of the study population.
The study sample was divided into 2 age groups:
< 65 years old and ≥ 65 years old. Most of the study
participants were of the second age category (63.3%).
For the purpose of this study, the results will focus on
C&H classes that require alveolar bone augmentation
(i.e., Classes IV, V and VI).
Fig. 2b
Statistical analysis
Random intercept univariate and multivariable linear
regression models were fitted to evaluate the effect of
sex, age and side on the C&H classes, the number of
missing teeth and dimensions of virtual grafts (length,
height, width and volume). Statistical analyses were
performed using Stata 15 (StataCorp).
Results
A total of 120 patients contributed 120 CBCT scans
and 240 posterior mandibular segments. A total of
59 contralateral mandibular segments were excluded
from the final analysis (25 in the left mandible and 34
in the right mandible), and 181 left and right mandibular segments were analyzed overall (95 in the left
mandible and 86 in the right mandible). The study participants were 47 males and 73 females with an age
range between 37 and 92 years (mean age = 66.2 ± 11.2
years; Table 1).
18
Frequency of bone loss patterns in posterior mandibles in relation to sex, age and side (Table 2)
Females showed higher frequencies of Classes IV,
V and VI in comparison with males (crude P value
< 0.001; adjusted P value = 0.001). Class V was the
most frequent class that requires augmentation in
females (30.3%), while 5.6% of males had Class V in
the posterior mandible. Class VI was the least frequent
in relation to Classes IV and V in both sexes (6.4% in
females; 2.8% in males).
Patients in the older age category showed higher
frequencies of Classes IV, V and VI in comparison
with younger patients (crude P value = 0.14; adjusted
P value = 0.31). The most frequent class that requires augmentation was Class V in older (22.0%) and
younger (17.5%) individuals.
In both mandibular sides, Class V was the most frequent class that requires augmentation in comparison
with Classes IV and VI. However, Class V was more
frequent in the right mandible than on the left side
(23.3% and 17.9%, respectively; crude P value = 0.03;
adjusted P value = 0.03).
Frequency of consecutively missing teeth in posterior mandibles in relation to sex, age and side
(Table 3)
Most of the posterior mandibular segments in females
had either 3 or 4 missing teeth (36.7%, 39.4%, respectively), while most of the mandibular segments in
males showed 3 missing teeth (44.4%). Nonetheless,
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Atrophic posterior mandibles and virtually designed grafts
Characteristics
Cawood & Howell classification
II
III
IV
V
VI
Total
Sex
n (%)
n (%)
n (%)
n (%)
n (%)
No. (%) of
mandibular
segments
Female
1 (0.9)
52 (47.7)
16 (14.7)
33 (30.3)
7 (6.4)
109 (100)
Male
1 (1.4)
60 (83.3)
5 (6.9)
4 (5.6)
2 (2.8)
72 (100)
Crude P value*
< 0.001
Adjusted P value**
0.001
Age
< 65 years
0 (0.0)
45 (71.4)
7 (11.1)
11 (17.5)
0 (0.0)
63 (100)
≥ 65 years
2 (1.7)
67 (56.8)
14 (11.9)
26 (22.0)
9 (7.6)
118 (100)
Crude P value*
0.14
Adjusted P value**
0.31
Side
Left
1 (1.0)
62 (65.3)
11 (11.6)
17 (17.9)
4 (4.2)
95 (100)
Right
1 (1.2)
50 (58.1)
10 (11.6)
20 (23.3)
5 (5.8)
86 (100)
Crude P value*
0.03
Adjusted P value**
0.03
* From random intercept univariate linear regression models.
** From random intercept multivariable linear regression models
containing all three variables.
Characteristics
Table 2: Frequency of different bone loss patterns in posterior
mandibles in relation to sex, age and side.
No. (%) of consecutively missing posterior teeth
Total
2
3
4
No. (%) of
mandibular
segments
Female
26 (23.9)
40 (36.7)
43 (39.4)
109 (100)
Male
24 (33.3)
32 (44.4)
16 (22.2)
72 (100)
Sex
Crude P value**
0.11
Adjusted P value**
0.21
Age
< 65 years
23 (36.5)
26 (41.3)
14 (22.2)
63 (100)
≥ 65 years
27 (22.9)
46 (39.0)
45 (38.1)
118 (100)
Crude P value*
0.04
Adjusted P value**
0.06
Side
Left
25 (26.3)
39 (41.1)
31 (32.6)
95 (100)
Right
25 (29.1)
33 (38.4)
28 (32.5)
86 (100)
Crude P value*
0.47
Adjusted P value**
0.47
* From random intercept univariate linear regression models.
** From multivariable linear regression models containing
all three variables.
Table 3: Frequency of consecutively missing teeth in posterior
mandibles in relation to sex, age and side.
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Cawood
& Howell
classification
No. (%) of consecutively missing
posterior teeth
2
3
4
II
0 (0)
1 (1.4)
1 (1.7)
III
40 (80)
49 (68)
23 (39.0)
IV
3 (6)
6 (8.3)
12 (20.3)
V
7 (14)
12 (16.7)
18 (30.5)
VI
0 (0)
4 (5.5)
5 (8.5)
50 (100)
72 (100)
59 (100)
Total No. (%)
* From random intercept univariate linear regression models.
** From multivariable linear regression models containing
all three variables.
Crude P
value*
Adjusted P
value**
0.04
0.04
Table 4: Number of consecutive missing teeth in posterior
mandibles in relation to Cawood and Howell
classification.
Virtual graft dimension
Two missing teeth
(n = 6)
Three missing teeth
(n = 13)
Four missing teeth
(n = 17)
Length (mean ± SD),
20.0 ± 0.6
23.9 ± 0.6
29.6 ± 0.7
mm
(reference)
(P < 0.001)
(P < 0.001)
Height (mean ± SD),
9.0 ± 0.9
9.4 ± 1.2
9.0 ± 0.8
mm
(reference)
(P = 0.39)
(P = 0.93)
Width (mean ± SD),
8.2 ± 0.4
8.1 ± 0.3
8.2 ± 0.4
mm
(reference)
(P = 0.74)
(P = 0.89)
1,469 ± 152
1,814 ± 248
2,177 ± 224
(reference)
(P = 0.001)
(P < 0.001)
Graft volume
(mean ± SD),
mm3
* P values from random intercept linear regression models
adjusted for sex, age and side.
sex did not seem to influence the number of consecutive missing teeth in the posterior mandible (crude
P value = 0.11; adjusted P value = 0.21).
Posterior mandibles in patients of ≥ 65 years of
age showed mostly 3 or 4 missing teeth (39.0% and
38.1%, respectively), while the posterior segments in
the younger age group showed mostly 2 or 3 missing
teeth (36.5% and 41.3%, respectively). These results
show that the number of missing teeth might be influenced by age (0.3 more missing teeth on average
among older patients; crude P value = 0.04; P = 0.06,
adjusted for sex and side).
20
Table 5: Height, width and length of virtual grafts of Cawood
and Howell Class V.
Both right and left posterior mandibles had comparable frequencies of the number of missing teeth. Three
missing teeth were the most frequent for both sides,
while 2 missing teeth were the least frequent (crude P
value = 0.47; adjusted P value = 0.47).
Frequency of consecutively missing teeth in posterior mandibles in relation to bone loss patterns
(Table 4)
Posterior mandibles that showed Classes IV, V and
VI had mostly 4 missing teeth. In Classes IV and V,
the frequency of 2 and 3 missing teeth was almost
comparable. None of the mandibles with Class VI had
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•
2 missing teeth (crude P value = 0.04; adjusted
P value = 0.04).
Dimensions of digital bone grafts for mandibular
segments with Class V (Table 5)
As Class V was the most frequent among classes that
require bone augmentation (i.e., the most frequent
among Classes IV, V and VI), virtual bone regeneration of Class V mandibular segments was performed
through digital bone grafts, using specific software.
Among the 181 analyzed mandibular segments, 37
segments were of Class V. However, virtual bone
regeneration was only performed for 36 segments,
as 1 segment was excluded owing to technical difficulties encountered with the provided CBCT scan of
the patient, which did not allow for the procedure to
be successfully performed. Regarding the length of
the virtual graft, the mean was 20 ± 0.6 mm when
2 teeth were missing. When 3 teeth were missing,
the mean length was 23.9 ± 0.6 mm. In cases of both
premolars and both molars missing, the mean length
was 29.6 ± 0.7 mm. Mean length was different based
on the number of missing teeth (P < 0.001).
As for the width of the virtual graft, it was almost
comparable when 2 (8.2 ± 0.4), 3 (8.1 ± 0.3) or 4 teeth
(8.2 ± 0.4) were missing (P > 0.05). Regarding the
height of the virtual graft, this dimension was also
comparable when 2 (9.0 ± 0.9), 3 (9.4 ± 1.2) or 4 teeth
(9.0 ± 0.8) were missing (P > 0.05).
Discussion
To the best of the authors’ knowledge, this is the first
retrospective study to analyze the frequency of C&H
classes on CBCT scans and virtually regenerate the
most frequent atrophic class that requires bone augmentation. As findings in the literature are inconsistent
regarding the severity of bone resorption in relation to
sex, the frequency of C&H classes between males and
females was compared in the present study as well.
The C&H classification14 was applied in this retrospective analysis because it is among the most used to categorize edentulous ridges15 and the different shapes of
a ridge of each class can be easily identified on CBCT
scans.16 To date, there is only 1 study that assessed
the frequency of C&H atrophic stages. However, this
investigation was in a historic nation and only evalu-
ated the association between age and frequency/severity of atrophy.18 After the frequency analysis of bone
resorption patterns, dimensions of digital grafts were
assessed as well, to determine whether the virtual
grafts could be grouped into distinct clusters, which
could allow the fabrication of bone grafts of standardized dimensions that could be applied in the majority of
clinical cases.
The findings of the present study suggest that
females show higher frequencies of severe atrophic
stages in comparison with males; thus, sex tends to
influence bone resorption. These results are consistent
with what has been previously reported in the literature. Solar et al. suggested that female sex was an independent risk factor for more severe bone resorption
in the mandible.19 In another study, female sex was indicated as a risk factor for greater bone resorption in
the posterior mandible;20 however, this study focused
on patients wearing conventional dentures and implant
overdentures. Interestingly, the tendency of females to
show more bone resorption than their male counterparts might be due to females having deeper resorption lacunae.21 In a different investigation, more severe
resorption in females was due to lower bone mineral
content of the mandible in young dentate women when
compared with young dentate men.22 As is known, the
less highly mineralized a substrate is, the more easily
it can resorb.23 In contrast, Winter et al. reported more
bone loss in the posterior mandible in males, due to
greater biting force.24
In the present retrospective analysis, C&H Class V
was the most frequent among the 3 atrophic classes
that require bone augmentation (i.e., Classes IV, V
and VI) among all study participants, while Class VI
was the least frequent. In a retrospective analysis of
a historic nation, atrophy stages V and VI were both
the most frequent among older age groups.18 Since the
population of the present retrospective analysis is not
historic, the negligible frequency of class VI frequency
can be justified by the fact that patients do seek dental
treatment at some point before bone resorption progresses to basal bone. As expected, the older age group
(≥ 65 years) in the current retrospective analysis
showed more severe C&H classes of resorption in
comparison with the younger age group (< 65 years).
Similarly, in a historic nation, the severity of bone resorption was associated with the individual’s age.18
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Atrophic posterior mandibles and virtually designed grafts
Moreover, the results of the present study revealed
that the number of missing teeth is influenced by age.
As Class V was the most frequent among the atrophic classes that require bone augmentation, all
Class V cases were virtually regenerated with digital
bone grafts. This procedure was guided by virtual
implant placement, to ensure that the dimensions of the
virtual grafts were correct. Based on these dimensions,
3 clusters were notable—graft length of 21, 25 and
30 mm—based on the number of missing teeth. In
these clusters, graft width and height were almost
comparable (8 mm and 9 mm, respectively). Therefore,
it might be logical to propose that using prefabricated bone grafts in most clinical case scenarios
could be practical and applicable. Utilization of prefabricated bone grafts could be more applicable in
right mandibles in females and older patients, based
on the results of the current study.
Whether the prefabricated graft may need minimal
or major modification for adaptation is to be confirmed
in a future study, by calculating and comparing the adaptation ratio of both the virtual and actual grafts. It
has been suggested that shaping and modification of a
chairside graft highly increase the risk of contamination
and subsequent infection, which could compromise
the outcomes of the bone regeneration procedure.17
In the present study, the virtual bone augmentation
procedure was guided by virtual placement of dental
implants. One might argue that dental implants shorter
than 10 mm can be used in posterior mandibles with
predictable outcomes. Indeed, short dental implants
are a valid option for restoring posterior mandibular
Although the current study suggests 3 different
volumes of bone grafts based on the number of missing
teeth, this aspect represents just 1 component of the
entire clinical paradigm. In fact, case management is
influenced by various factors that must be taken into
consideration: the patient’s socio-economic status; application of the short dental arch concept; length, diameter and number of dental implants; and utilization
of a removable prosthesis instead of implant therapy.
Although one might think that the bone graft volumes
generated might be insufficient at the time of implant
surgery, as graft resorption during osseous healing is
still not predictable, it must be noted that prefabricated
grafts could be made of biomaterials that have a degradation rate in concordance with the remodeling processes of the target tissue.10 In this context, a 2-step
regenerative protocol can be implemented: pre-augmentation STE technique (Fig. 3),5, 28 followed by regeneration with prefabricated grafts. In this approach,
a suitable self-inflating soft-tissue expander and its
Tissue expansion
soft tissue
jaw bone
tissue expander
Lack of soft tissue
regions, as is vertical bone augmentation combined
with implants of standard length (i.e., 10 mm);25, 26
however, since the aim of the present study was to
analyze the virtual graft dimensions, the second treatment option was adopted (i.e., vertical bone augmentation), and a virtual implant of standard length was
used to guide the virtual bone augmentation procedure. Narrow implants (i.e., 3.25 mm) were used, as
their successful application in the posterior mandible
has been previously reported as a minimally invasive
alternative to horizontal bone augmentation.27 Therefore, placing a virtual implant with a narrow diameter
was done in order to decrease the horizontal bulkiness
of the graft.
Insertion of tissue expander
Autonomous growth
New soft tissue, created by
tissue expander
Explantation and
bone augmentation
Fig. 3
22
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Atrophic posterior mandibles and virtually designed grafts
corresponding bone graft volume are chosen for each
individual patient after thorough treatment planning of
the case. The virtual graft volumes obtained in this retrospective study appear to correlate to the available
soft-tissue expander volumes. For example, the mean
virtual graft volume obtained when 4 posterior mandibular teeth were missing was 2,177 mm3. This corresponds to the 2.1 mL (2,100 mm3) final-volume expander. Therefore, utilizing an expander of this volume
and the corresponding bone graft volume could be
applicable in a Class V posterior mandible with
4 missing teeth. Likewise, the mean virtual graft volume
when 3 teeth were missing was 1,814 mm3. The matching soft-tissue expander volume in this case would be
either a 1.3 or a 2.1 mL final-volume expander. In the
case of 2 missing teeth, the mean virtual graft volume
was 1,469 mm3, suggesting that a 1.3 mL final-volume
expander would be the most suitable in this clinical situation. However, future studies focused on soft-tissue
expanders and their corresponding graft volumes are
needed to confirm these preliminary findings and the
benchmark values generated.
The results of this retrospective study should be interpreted with caution, as it has certain limitations. The
inclusion criteria for the analyzed CBCT scans, obtained from the same dental practice, were developed
for the purposes of utilizing prefabricated grafts, and
thus, our findings are not generalizable. As this was a
pilot investigation, only areas with a free-end saddle
were evaluated, thus excluding bounded saddle areas
consisting of a missing second premolar and missing
first molar. Therefore, further studies, also with larger
sample sizes, are still needed.
mentation protocol: pre-augmentation STE technique,
followed by regeneration with prefabricated grafts.
This protocol could facilitate bone augmentation procedures for clinicians and decrease patient morbidity,
especially in the case of complex defects.
Acknowledgments
This study was supported by Geistlich Pharma AG
(Wolhusen, Switzerland). The authors would like to
thank Dr. Birgit Schäfer from Geistlich Pharma for her
valuable advices and assistance with this study. The
authors would also like to thank Mr. Gianluca Vitrano
and 3DMed (L’Aquila, Italy) for providing the software
used in this study and for the technical support.
Competing interests
The authors report no conflict of interest related to this
study.
Legends
Fig. 1 – Appearance of different Cawood and Howell
Conclusion
Class V atrophy was the most common among the
C&H classes that require bone augmentation in the
right mandible and among females and the older age
group. Virtual regeneration of Class V defects suggested the possibility of 3 clusters of bone grafts, depending on the number of missing teeth. Further studies are
needed to evaluate the adaptation ratio between the
virtual and actual grafts to conclude whether the grafts
need minor or major shaping and modification at chairside before clinical application. Moreover, the current
findings might help in developing a 2-step bone aug-
classes on CBCT scans “Courtesy of Saavedra-Abril
J A, Balhen-Martin C, Zaragoza-Velasco K, et al.
Dental multisection CT for the placement of oral implants: Technique and applications. Radiographics
2010;30:1975-1991” Reference 16. Figure is used by
permission of RSNA (Radiological Society of North
America).
Fig. 2a – Creation and positioning of virtual bone grafts
using OS3D 2.0 software.
Fig. 2b – Virtual placement of dental implants using the
software as guidance for virtual graft reconstruction of
a Cawood and Howell Class V.
Fig. 3 – Pre-augmentation soft-tissue expansion tech-
nique (with permission of osmed, Ilmenau, Germany).
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Atrophic posterior mandibles and virtually designed grafts
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2016 May;27(5):505–22.
6. Moroni L, De Wijn JR, Van Blitterswijk CA. 3D fiber-deposited scaffolds for tissue engineering: influence of pores geometry and architecture on dynamic
mechanical properties.
→ Biomaterials.
2006 Mar;27(7):974–85.
7. Laino L, Iezzi G, Piattelli A, Lo Muzio L, Cicciù M.
Vertical ridge augmentation of the atrophic posterior
mandible with sandwich technique: bone block from
the chin area versus corticocancellous bone block allograft—clinical and histological prospective randomized controlled study.
→ Biomed Res Int.
2014;2014:982104. doi: 10.1155/2014/982104.
24
10. Asa’ad F, Pagni G, Pilipchuk SP, Giannì AB, Giannobile WV, Rasperini, G. 3D-printed scaffolds and biomaterials: review of alveolar bone augmentation and periodontal regeneration applications.
→ Int J Dent.
2016;2016:1239842. doi: 10.1155/2016/1239842.
11. Venet L, Perriat M, Mangano FG, Fortin T. Horizontal
ridge reconstruction of the anterior maxilla using customized allogeneic bone blocks with a minimally invasive technique—a case series.
→ BMC Oral Health.
2017 Dec 8;17(1):146. doi: 10.1186/s12903-017-0423-0.
12. Metzger MC, Schön R, Tetzlaf R, Weyer N, Rafii A,
Gellrich NC, Schmelzeisen R. Topographical CT-data
analysis of the human orbital floor.
→ Int J Oral Maxillofac Surg.
2007 Jan;36(1):45–53.
13. Sezer A, Altan L, Özdemir Ö. Multiple comparison
of age groups in bone mineral density under heteroscedasticity.
→ Biomed Res Int.
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→ Int J Oral Maxillofac Surg.
1988 Aug;17(4):232–6.
15. Rossetti PH, Bonachela WC, Rossetti LM. Relevant
anatomic and biomechanical studies for implant possibilities on the atrophic maxilla: critical appraisal and
literature review.
→ J Prosthodont.
2010 Aug;19(6):449–57.
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[25] =>
Atrophic posterior mandibles and virtually designed grafts
16. Saavedra-Abril J, Balhen-Martin C, Zaragoza-Velasco K, Kimura-Hayama ET, Saavedra S, Stoopen ME.
Dental multisection CT for the placement of oral implants: technique and applications.
→ Radiographics.
2010 Nov;30(7):1975–91.
24. Winter CM, Woelfel JB, Igarashi T. Five-year
changes in the edentulous mandible as determined on
oblique cephalometric radiographs.
→ J Dent Res.
1974 Nov–Dec;53(6):1455–67.
17. Jacotti M, Barausse C, Felice P. Posterior atrophic
mandible rehabilitation with onlay allograft created with
CAD-CAM procedure: a case report.
→ Implant Dent.
2014 Feb;23(1):22–8.
25. Lops D, Bressan E, Pisoni G, Cea N, Corazza B,
Romeo E. Short implants in partially edentulous maxillae and mandibles: a 10 to 20 years retrospective evaluation.
→ Int J Dent.
2012;2012:351793. doi: 10.1155/2012/351793.
18. Reich KM, Huber CD, Lippnig WR, Ulm C, Watzek
G, Tangl S. Atrophy of the residual alveolar ridge following tooth loss in an historical population.
→ Oral Dis.
2011 Jan;17(1):33–44.
26. Thoma DS, Cha JK, Jung UW. Treatment concepts
for the posterior maxilla and mandible: short implants
versus long implants in augmented bone.
→ J Periodontal Implant Sci.
2017 Feb;47(1):2–12.
19. Solar P, Ulm CW, Thornton B, Matejka M. Sex-related differences in the bone mineral density of atrophic
mandibles.
→ J Prosthet Dent.
1994 Apr;71(4):345–9.
27. Grandi T, Svezia L, Grandi G. Narrow implants (2.75
and 3.25 mm diameter) supporting a fixed splinted
prostheses in posterior regions of mandible: one-year
results from a prospective cohort study.
→ Int J Implant Dent.
2017 Sep 8;3(1):43. doi: 10.1186/s40729-017-0102-6.
20. Kordatzis K, Wright PS, Meijer HJ. Posterior mandibular residual ridge resorption in patients with conventional dentures and implant overdentures.
→ Int J Oral Maxillofac Implants.
2003 May–Jun;18(3):447–52.
21. Devlin H, Sloan P, Luther F. Alveolar bone resorption: a histologic study comparing bone turnover in the
edentulous mandible and iliac crest.
→ J Prosthet Dent.
1994 May;71(5):478–81.
28. Asa’ad F, Bellucci G, Ferrantino L, Trisciuoglio D,
Taschieri S, Del Fabbro M. Preaugmentation soft tissue
expansion: a report of four pilot cases.
→ Case Rep Dent.
2018 Apr 19;2018:3162617. doi: 10.1155/2018/3162617.
22. Von Wowern N. Bone mineral content of mandibles:
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→ Calcif Tissue Int.
1988 Oct;43(4):193–8.
23. Jones SJ, Arora M, Boyde A. The rate of osteoclastic destruction of calcified tissues is inversely proportional to mineral density.
→ Calcif Tissue Int.
1995 Jun;56(6):554–8.
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[26] =>
Autotransplantation in odontoma patient
Autotransplantation: Salvaging an
odontoma-associated unerupted
anterior tooth
Min Jim Lim,a
Ab Ghani Nurul Karimaha &
Tengku Shaeran Tengku Aszraf a
a
Oral Maxillofacial Surgery Department,
Hospital Tanah Merah, Tanah Merah, Kelantan,
odontomas. The odontomas were surgically removed
and the impacted maxillary left central incisor placed
into occlusion and held in situ using a composite splint.
Root canal therapy was carried out in a single visit at
her subsequent appointment. The composite splint
was retained for 6 weeks.
Malaysia
Corresponding author:
Dr. Min Jim Lim
Pejabat Kesihatan Pergigian Daerah Tanah Merah
Jalan Pasir Mas
17500 Tanah Merah
Kelantan
Malaysia
minjimlim@hotmail.com
How to cite this article: Lim MJ, Ab Ghani NK,
Tengku Shaeran TA. Autotransplantation: Salvaging
an odontoma-associated unerupted anterior tooth.
J Oral Science Rehabilitation. 2019 Jun;5(2):26–33.
Abstract
Conclusion
Autotransplantation has advantages and disadvantages in the case of tooth impaction. The treatment
must be considered individually, and the patient must
be fully informed of the procedure involved.
Keywords
Tooth autotransplantation; impacted tooth; odontoma.
Background
Autogenous tooth transplantation is a viable option in
cases involving impacted teeth, congenitally missing
teeth, tooth loss and ectopic teeth. The method is
considered superior to a removable prosthesis, as it
maintains proprioception and alveolar bone height.
Compared with dental implants, autotransplantation
can provide faster healing, function and esthetic improvement at minimal cost.
Case presentation
The first case involved a patient referred for an
unerupted maxillary left central incisor associated with
26
The second case involved a patient referred owing
to eruption of multiple small tooth-like structures at her
maxillary right central incisor. A diagnosis of an impacted maxillary right central incisor secondary to erupted
odontomas was made. The procedure of autotransplantation was carried out in stages, first removing the
odontomas and clearing the recipient site of infection,
followed by surgical repositioning of the impacted maxillary central incisor. Its root canal therapy was completed in a single visit later, and the tooth continued
to be retained by a composite splint for the duration of
6 weeks.
Introduction
Autotransplantation is a procedure that entails relocating the patient’s own teeth from 1 site in the oral
cavity to another. Ectopic teeth, tooth loss or congenitally missing teeth are among the clinical situations
for which autotransplantation is indicated.1 Unlike a
removable prosthesis, an autotransplanted tooth provides proprioceptive properties during function and
allows maintenance of the alveolar bone mass. Therefore, it not only serves to fill the empty ridge for esthetic
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[27] =>
Autotransplantation in odontoma patient
Odontoma is the most common odontogenic tumor,
and its presence may be associated with delayed
eruption or total impaction of dentition. Although it can
be either complex or compound in nature, the type of
odontoma does not have any significant clinical effect.
Usually, odontomas can be found in the maxillary
anterior region, affecting development and eruption
of maxillary central incisors and canines. The diagnosis of odontoma is often a coincidental radiographic
finding, resulting from investigation of delayed eruption
or absence of a tooth in the arch.
Fig. 1
In this article, we highlight 2 cases of autotransplantation of impacted maxillary central incisors after
removal of embedded and erupted odontomas, respectively.
Case presentation
Fig. 2
purposes, but restores a normal, functional dentition
at a relatively lower treatment cost compared with
implants, a fixed prosthesis or orthodontic closure.
Survival of the transplanted tooth is influenced by
the preoperative, peroperative and postoperative conditions. Preoperatively, the donor tooth must be evaluated regarding its suitability for transplantation elsewhere on the ridge. This includes the morphology of
its crown and roots, presence of associated pathologies and state of the recipient site. Cautious handling
of the tooth during its transfer from its original site to
the new bed, the proper surgical technique and good
immobilization following that also contribute to the
good prognosis of the transplanted tooth. The patient’s
commitment to maintaining excellent oral hygiene and
compliance with the postoperative instructions are no
doubt indispensable.2
Case 1
A 17-year-old female patient was referred to our oral
maxillofacial surgery unit for eruption failure of the
maxillary left central incisor. She had no contributory
medical history that may have been associated with
this condition. The patient reported that her primary
maxillary left central incisor had exfoliated at the age
of 8 years and following that no permanent tooth had
come into occlusion. On oral examination, there was
no palpable swelling or protuberance that might indicate the presence of the maxillary left central incisor
(Fig. 1). A cone beam computed tomography (CBCT)
scan was taken, and it revealed a cluster of multiple
radiopaque tooth-like structures in the maxillary left anterior region. Adjacent to these lay the impacted maxillary left central incisor, in a horizontal orientation close
to the nasal floor (Fig. 2). A diagnosis of a horizontal
impacted maxillary left incisor secondary to odontomas
was made. The patient was informed about the treatment options available and she opted for the impacted
central incisor to be salvaged.
Under general anesthesia, an intrasulcular incision
was made from the maxillary right central incisor to
the maxillary left lateral incisor, with releasing incisions
made on both ends. A full-thickness flap was raised.
Buccal bone was removed to expose the odontoma
cluster and a total of 13 denticles were then removed
(Fig. 3). Just above the cluster of odontomas, the im-
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[28] =>
Autotransplantation in odontoma patient
28
Fig. 3
Fig. 6
Fig. 4
Fig. 7
Fig. 5
Fig. 8
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Autotransplantation in odontoma patient
Fig. 9
Fig. 10
pacted central incisor was identified. Care was taken
to remove this tooth as atraumatically as possible to
avoid fracture, and the patient’s own blood was used
to preserve it while the recipient bed was prepared
(Fig. 4). The tooth was then transplanted into position with the best possible occlusion using composite
and stainless-steel wire (Fig. 5). Four weeks after the
surgery, root canal therapy was completed in a single
visit, and 2 weeks after that, the splint was removed,
leaving the tooth with normal mobility and occlusal
function.
incisor (Fig. 8). A slight palpable bulge could be felt at
the vestibule above the maxillary right central incisor
region. A maxillary occlusal radiograph revealed a
cluster of radiopaque tooth-like structures at the alveolar ridge and an impacted maxillary central incisor lying
close by (Fig. 9). A diagnosis of an impacted maxillary
right central incisor secondary to erupted odontomas
was made. The possibility of autotransplantation was
discussed with the patient and she keenly expressed
her full commitment.
Six months after surgery, follow-up examination
showed a satisfactory appearance (Fig. 6), normal
tooth mobility and no discoloration of the transplanted
tooth. The dental panoramic tomogram showed good
bony healing around the cervical and middle thirds of
the root (Fig. 7).
Case 2
A 19-year-old female patient was referred to our unit
owing to the presence of multiple small teeth occupying
her maxillary right central incisor region. She reported
that these had erupted after her primary teeth had exfoliated at the age of 7 years. On examination, multiple
tooth-like structures were found to be occupying the
space between the right lateral incisor and left central
Extraction of all the erupted odontomas was performed under local anesthesia and the site was
allowed to heal before the transplantation procedure
was carried out. This was to clear the future transplantation site of any infection, as it was noted that there
was a labial sinus that had highly likely arisen from 1
of the odontoma. The neighboring teeth were all vital
without pocketing.
After 2 weeks, local anesthesia was administered,
and an incision was made from the maxillary right
canine to the maxillary left lateral incisor, with bilateral
releasing incisions. A full-thickness flap was raised
to expose any remaining odontoma. A single odontoma was revealed and removed. The impacted central
incisor was exposed, meticulously luxated and kept in
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[30] =>
Autotransplantation in odontoma patient
Fig. 11
Fig. 12
the patient’s own blood. Slight guttering was done on
the alveolar bone to accommodate the central incisor
(Fig. 10). The tooth was splinted into position and
kept in the best possible occlusion with composite and
stainless-steel wire (Fig. 11). Root canal therapy was
done 4 weeks after the surgery and the splint removed
2 weeks thereafter.
Follow-up examination after 6 months showed a
satisfactory appearance, normal tooth mobility and no
discoloration of the transplanted tooth (Fig. 12). A periapical radiograph was taken and revealed good bony
healing around the transplanted tooth (Fig. 13).
30
Discussion
Tooth relocation involving a site previously occupied
by odontomas is not common practice, as it is not part
of any identified indication for autotransplantation.2
Certain cases of an impacted tooth associated with the
presence of odontoma can be managed through spontaneous eruption or orthodontics-assisted eruption
after removal of the physical obstructions. According to
Ashkenazi et al., spontaneous eruption of an impacted
tooth correlates with several conditions, such as the
distance of the impacted tooth’s apex from its proper
position, impaction depth, angle of impaction relative
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Autotransplantation in odontoma patient
normal crown sizes, and even though their roots were
slightly shorter than those of the erupted counterparts,
they were nondilacerated. Regarding availability of
space, there was ample room for transplantation of the
impacted tooth in case 1. The space had been maintained by provision of a maxillary partial denture by the
patient’s previous dentist and partly by the presence
of the odontomas underneath. In case 2, the space
for transplantation was slightly limited by the palatally erupted lateral incisor. The oral hygiene of both
patients was good, and they were eager to have their
impacted teeth brought into position and functional in
normal occlusion.
Among the drawbacks of tooth autotransplantation
that should be highlighted to patients before embarking on this procedure are the risks of ankylosis of the
transplanted tooth, inflammatory resorption, tooth discoloration and possible loss in subsequent years.
Fig. 13
to the midline, and timing of surgery relative to the expected eruption.3 In a retrospective study of unerupted
maxillary incisors associated with supernumerary teeth
by Mason et al., three-quarters of the immature teeth
erupted spontaneously, while half of the mature teeth
needed a second surgery to bring them into occlusion.4
Their findings support the theory that unerupted incisors with closed apices are associated with slow eruptive movement.5 Both of our patients were not suitable
candidates for such treatment methods. Their impacted
teeth had fully developed roots and large angles of
impaction. Spontaneous eruption was very unlikely.
Surgical exposure and orthodontic alignment too were
not options owing to the teeth’s unfavorable positions
and depths of impaction.
In our patients, tooth autotransplantation had been
offered as a treatment choice after considering several
factors. First of all, radiographic investigation had revealed that the impacted tooth was not associated
with a suspicious cystic or other pathological lesion,
apart from the odontomas hindering its normal eruption. Morphologically, both of the impacted teeth had
The survival rates of autotransplanted teeth vary.
Overall, teeth with immature root formation have higher
survival and success rates compared with mature
teeth.6 One study has even shown survival rates of
autotransplanted teeth with complete root formation to
be as high as 98% for 1 year and 90% for 5 years.7
This finding indicates that, even with complete root formation, autotransplantation can be a viable, relatively
economical option for replacement of missing teeth.
Autotransplantation is seen as a technique-sensitive
procedure for which maintenance of the periodontal ligament is very crucial. Continued vitality of this
structure is the most significant determinant for
survival of the transplanted tooth.6 To allow proper
differentiation of periodontal ligament cells, it is
essential to minimize inflammation surrounding the
transplanted tooth. Sources of potential inflammation
must be eliminated, such as through tight suturing of
gingival cuff to prevent bacterial ingress 8 and good
timing of root canal therapy (RCT).6 It has been suggested that RCT of fully developed donor teeth should
be started 2 weeks after transplantation, to keep
trauma as minimal as possible during the initial healing
phase of reattachment of the periodontal ligament.
Further delay will increase the risk of pulpal infection,
which in turn will increase the possibility of secondary
inflammatory resorption.6 RCT in both our patients was
started after 4 weeks of transplantation while the tooth
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[32] =>
Autotransplantation in odontoma patient
was still in a splinted position. The rationale of this is
to allow adequate reattachment of the periodontal ligament and more bone deposition before subjecting the
tooth to the motion of the cleaning and shaping of RCT.
We decided to complete the RCT in a single visit, as
the tooth was asymptomatic in each case. There is insufficient evidence to show whether multiple-visit RCT
is superior to single-visit RCT or vice versa.9
Other than good alveolar bone support and adequate keratinized tissue, the recipient site must be
free from acute and chronic infections.10 Therefore,
apart from an aseptic technique, a systemic antibiotic
was given to increase the prognosis of the relocated
tooth. Without its use, the occurrence of root resorption has been reported to be 1.4 times higher.7 The
results clearly demonstrate the clinical benefit of giving
systemic antibiotics to increase the survival of autotransplanted teeth.7 For an antibiotic regimen, we
adopted the guideline for management of an avulsed
tooth, which recommends the use of tetracycline
or amoxicillin.11 We prescribed to our patients oral
amoxicillin (500 mg) 3 times daily for 1 week duration.
Surgical removal of impacted teeth and intraosseous odontomas might necessitate bone grafting to fill
up the bone cavity created. The required material may
be taken from the patient as an autogenous graft or
processed bone granules may be utilized. However, if
the cavity is small and the circumference of the bone
surrounding the transplanted tooth is good enough,
bone grafting may not be needed at all. A scaffold to
promote blood clotting and provide a growth factor
reservoir can be achieved by oxidized cellulose
polymer, which is readily available in the clinic.
The first case report of combined odontoma removal
and autotransplantation was by Hwang et al.12 After
14 months of follow-up, the case had shown a satisfactory result in terms of appearance and periodontal
status.12 Both of our cases resemble theirs, with immediate replantation of unerupted maxillary anterior
teeth associated with odontomas in teenage patients.
The usefulness of this tooth relocation procedure compared with conventional prosthetic restoration such as
a dental implant is that the tooth is biological, and with
good preservation of the periodontal ligament, physiological stimulation will maintain the alveolar bone
height and width. It is also cost-effective, does not
32
entail sacrifice of adjacent tooth structure like bridgework preparation does and is more comfortable, as it
can be left in situ, unlike removable partial dentures.
The transplanted tooth is hoped to be able to serve its
function and esthetic purpose for as long as possible,
at least throughout the patient’s growing years. The
option of osseointegrated implants may present later,
when patients have reached adulthood and their jaw
growth is stabilized.
Conclusion
Immediate autotransplantation using the salvaged
impacted tooth can be considered by surgeons in the
management of edentulism, especially in the maxillary
anterior regions of growing adolescent patients. The
technique is relatively quick and inexpensive for addressing esthetic and functional demands. Nevertheless, it is important for the patient to fully understand
the procedure involved, as well as the advantages and
limitations of this method of tooth replacement.
Acknowledgments
We would like to thank the radiographic department
of the Raja Perempuan Zainab II hospital for the
provision of images. We would also like to thank the
Director-General of Health of the Malaysia Ministry of
Health for his permission to publish this article.
Competing interests
The authors declare that they have no competing
interests.
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Autotransplantation in odontoma patient
Legends
Fig. 1 – Clinical preoperative photograph of the patient
with absence of the permanent maxillary left central
incisor.
Fig. 2 – Sagittal view of the CBCT scan showing the pres-
ence of an impacted tooth in relation to the odontoma.
Fig. 3 – Intraoperative photograph of the odontomas.
Fig. 4 – Prepared recipient site.
Fig. 5 – Placement and splinting of the transplanted tooth.
Fig. 6 – Six-month postoperative photograph showing no
discoloration of the transplanted tooth.
Fig. 7 – Radiograph showing good bone healing without
signs of root ankylosis or root resorption.
Fig. 8 – Preoperative photograph showing erupted odon-
tomas with sinus opening.
Fig. 9 – Occlusal radiograph showing the impacted tooth.
Fig. 10 – Intraoperative photograph of the cavity after
removal of the impacted tooth.
Fig. 11 – Transplantation of the impacted tooth.
Fig. 12 – Six-month postoperative photograph showing
no discoloration of the transplanted tooth.
Fig. 13 – Radiograph showing good bone healing without
signs of root ankylosis or root resorption.
References
1. Thomas S, Turner SR, Sandy JR. Autotransplantation of teeth: is there a role?
→ Br J Orthod.
1998 Nov;25(4):275–82.
2. Nimčenko T, Omerca G, Varinauskas V, Bramanti E,
Signorino F, Cicciù M. Tooth auto-transplantation as an
alternative treatment option: a literature review.
→ Dent Res J (Isfahan).
2013 Jan;10(1):1–6.
3. Ashkenazi M, Greenberg BP, Chodik G, Rakocz
M. Postoperative prognosis of unerupted teeth after
removal of supernumerary teeth or odontomas.
→ Am J Orthod Dentofacial Orthop.
2007 May;131(5):614–9.
4. Mason C, Azam N, Holt RD, Rule DC. A retrospective study of unerupted maxillary incisors associated
with supernumerary teeth.
→ Br J Oral Maxillofac Surg.
2000 Feb;38(1):62–5.
5. Burke PH. The eruptive movements of permanent
central incisor teeth after surgical exposure.
→ Trans Eur Orthod Soc.
1963;39:251–61.
6. Chugh A, Aggarwal R, Chugh VK, Wadhwa P, Kohli
M. Autogenous tooth transplantation as a treatment
option.
→ Int J Clin Pediatr Dent.
2012 Jan;5(1):87–92.
7. Chung WC, Tu YK, Lin YH, Lu HK. Outcomes of
autotransplanted teeth with complete root formation: a
systematic review and meta-analysis.
→ J Clin Periodontol.
2014 Apr;41(4):412–23.
8. Yau EC. Tooth autotransplantation as a treatment
option.
→ Hong Kong Med Diary.
2009 Jun;14(6):21–4.
9. Schwendicke F, Göstemeyer G. Single-visit or multiple-visit root canal treatment: systematic review,
meta-analysis and trial sequential analysis.
→ BMJ Open.
2017 Feb 1;7(2):e013115. doi: 10.1136/bmjopen-2016013115.
10. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome of tooth transplantation: survival and
success rates 17–41 years posttreatment.
→ Am J Orthod Dentofacial Orthop.
2002 Feb;121(2):110–9; quiz 193.
11. Therapeutic Guidelines Limited. Therapeutic
Guidelines: Oral and Dental. 2nd version.
→ Melbourne: Therapeutic Guidelines Limited; 2012.
245 p.
12. Hwang LA, Kuo CY, Yang JW, Chiang WF. Autotransplantation of odontoma-associated impacted
teeth—a treatment strategy for satisfying immediate
esthetic demands: a case report.
→ J Oral Maxillofac Surg.
2017 Sep;75(9):1827–32.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
33
[34] =>
Myodynamic balance in children
Evaluation of the muscular activity and
myodynamic balance in children with
physiological dental occlusion
Nabi Nabiev,a
Tatiana Klimova,a
Gianfranco Cesaretti,b
Kazushige Tanaka,c
Daniele Botticellib &
Leonid Persina
a
Orthodontic Department, University of Moscow, Moscow, Russia
b
ARDEC Academy, Rimini, Italy
c
Osaka Dental University, Osaka, Japan
Corresponding author:
Dr. Gianfranco Cesaretti
ARDEC Academy
Viale Pascoli 67
Rimini
Italy
T: +39 335 220548
giancesa55@gmail.com
How to cite this article: Nabiev N, Klimova T, Cesaretti
G, Tanaka K, Botticelli D, Persin L. Evaluation of the
muscular activity and myodynamic balance in children
with physiological dental occlusion. J Oral Science
Rehabilitation. 2019 Jun;5(2):34–42.
Results
The electroactivity of the muscles measured with
root mean square and average rectified value did not
present statistically significant differences between the
groups, even though different values in relation to age
were found. Among the 7- to 9-year-olds, the root mean
square index in maximum clenching for the masticatory muscles was 256.5 ± 9.0 μV on the right and
254.0 ± 7.3 μV on the left and for the suprahyoid
muscles was 27.3 ± 3.2 μV and 31.6 ± 3.7 μV, respectively. In the group of 10- to 12-year-olds, the values
were 374.8 ± 15.5 μV and 354.0 ± 16.4 μV, respectively, for the masticatory muscles and 23.4 ± 1.9 μV and
22.4 ± 2.1 μV, respectively, for the suprahyoid muscles.
Conclusion
Any deviation from the values reported in the present
study suggests the presence of occlusal and/or postural problems.
Keywords
Clinical research protocol; clinical trial; randomized
controlled trial; dental occlusion; stomatognathic
system; masticatory system; orthodontics
Abstract
Objective
The objective was to evaluate the homogeneous myoelectric activity of the maxillofacial area and to identify
the myodynamic musculature balance in children of
different ages with a physiological dental occlusion.
Materials and methods
Sixty children, 30 aged 7–9 years and 30 aged
10–12 years, with an Angle Class I relationship and
34
who had no clinical symptoms, temporomandibular
disorders, cross bite, deep bite or open bite, and were
not bruxers underwent a surface electromyographic
examination. The bioelectric potentials of the left and
right temporalis, masseter, suprahyoid and sternocleidomastoid muscles were evaluated in maximum
clenching.
Introduction
Surface electromyography (sEMG) is an objective information tool of the functional state of the neuromuscular system of the masticatory apparatus.1 Technological progress has made it possible to extend the scope
of measurement tools in stomatology; the development
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[35] =>
Myodynamic balance in children
Fig. 1
of digital techniques has allowed the creation of surface
electromyographs that combine analog equipment and
computers. The latter receives the signals detected by
the surface electromyograph in digital and then processes and displays them in tables, histograms and
other graphs (Fig. 1).
The use of surface electromyographs requires
precise information on the normal average values of
average normality of different age groups and of the
muscular biopotentials, both for agonist and antagonist muscles, with particular reference to the temporalis, masseter, suprahyoid and sternocleidomastoid
muscles. Several studies have compared the outcomes of adults with adults,2–6 children with adults7
and children with children,8–13 showing in every case
different occlusal diseases. To date, the muscular activity of the masticatory complex in healthy children of
different ages with a physiological dental occlusion has
not been considered.
The present study was aimed at evaluating the
homogeneous myoelectric activity of the maxillofacial area and at identifying the myodynamic muscu-
lature balance (masseter, temporalis and suprahyoid
muscles) in children of different ages with a physiological dental occlusion. Physiological dental occlusion
was regarded as an Angle Class I relationship and
no clinical symptoms, temporomandibular disorders,
cross bite, deep bite, open bite or bruxism. The null
hypothesis was that myoelectric activity in children is
associated with age, which is the reason 2 age groups
were selected.
Materials and methods
Sixty children, 30 aged 7–9 years and 30 aged 10–12
years, with physiological dental occlusion, underwent
an electromyographic examination. The bioelectric
potentials of the left and right temporalis, masseter,
suprahyoid and sternocleidomastoid muscles were
evaluated with the BioKeyNet surface electromyograph (Bioket, San Benedetto del Tronto, Italy). The
biopotentials of the muscles were recorded using
single-use surface electrodes, taking into account the
recommendations of various authors.1, 14, 15
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
35
[36] =>
Myodynamic balance in children
Fig. 2
Fig. 3
36
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[37] =>
Myodynamic balance in children
RMS
Muscle ratio
P value
Right
Left
Temporalis + masseter
256.5 ± 9.0
254.0 ± 7.3
> 0.05
Suprahyoid
27.3 ± 3.2
31.6 ± 3.7
> 0.05
Ratio φ mass.tempor./φ suprahyoid
9.4
8.0
N/A
Sternocleidomastoid
23.4 ± 4.2
19.7 ± 3.2
> 0.05
ARV
Muscle ratio
P value
Right
Left
Temporalis + masseter
156.1 ± 5.0
156.7 ± 4.1
> 0.05
Suprahyoid
19.0 ± 2.6
23.8 ± 3.0
> 0.05
Ratio φ mass.tempor./φ suprahyoid
8.2
6.6
N/A
Sternocleidomastoid
8.5 ± 0.9
10.9 ± 1.1
> 0.05
φ Mass.tempor. = total value of biopotentials of temporalis and masseter muscles.
φ Suprahyoid = mean values of biopotentials of the suprahyoid muscles.
Table 1:
Myodynamic balance of maxillofacial muscles at the time of dental clenching at maximum effort
in 7- to 9-year-old children 7-9 years old with physiological occlusion (RMS and ARV in μV).
RMS
Muscle ratio
P value
Right
Left
Temporalis + masseter
374.8 ± 15.5
354.0 ± 16.4
> 0.05
Suprahyoid
23.4 ± 1.9
22.4 ± 2.1
> 0.05
Ratio φ mass.tempor./φ suprahyoid
16.0
15.8
N/A
Sternocleidomastoid
24.3 ± 2.9
22.9 ± 3.5
> 0.05
ARV
Muscle ratio
P value
Right
Left
Temporalis + masseter
242.7 ± 11.7
226.7 ± 10.2
> 0.05
Suprahyoid
15.8 ± 1.3
15.4 ± 1.5
> 0.05
Ratio φ mass.tempor./φ suprahyoid
15.3
14.7
N/A
Sternocleidomastoid
15.3 ± 2.1
16.2 ± 1.8
> 0.05
φ Mass.tempor. = total value of biopotentials of temporalis and masseter muscles.
φ Suprahyoid = mean values of biopotentials of the suprahyoid muscles.
Table 2:
Myodynamic balance of maxillofacial muscles at the time of dental clenching at maximum effort
in 10- to 12-year-old children with physiological dental occlusion (RMS and ARV in μV).
On the skin in the motor area of the muscle under examination, pre-gelled self-adhesive electrodes based
on silver chloride were fixed parallel to the muscular
fibers, with an interelectrode distance of 22 mm. The
configuration of the input channels of the surface electromyograph is of the differential type: (i) the poten-
tial difference between the positive electrode and the
negative electrode is detected; (ii) a reference electrode (ground) is placed in a zone nonelectrically connected to the points to be monitored. The bioelectric
signal arising from the muscle fibers, when the skin is
reached, is detected by the electrodes and then ampli-
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
37
[38] =>
Myodynamic balance in children
Fig. 4
Indexes
RMS
ARV
Muscles
Right
Left
Right
Left
Temporalis
125.4 ± 9.8
143.1 ± 7.3
91.4 ± 6.5
93.6 ± 4.5
Masseter
131.1 ± 9.2
111.0 ± 7.5
64.7 ± 3.9
63.1 ± 3.8
Suprahyoid
27.3 ± 3.2
31.6 ± 3.7
19.0 ± 2.6
23.8 ± 3.0
Sternocleidomastoid
23.3 ± 4.2
19.7 ± 3.2
8.5 ± 0.9
10.9 ± 1.1
Table 3: Myodynamic balance of maxillofacial muscles at the time of dental clenching at maximum effort
in 7- to 9-year-old children with physiological dental occlusion (RMS and ARV in μV).
Indexes
RMS
ARV
Muscles
Right
Left
Right
Left
Temporalis
144.6 ± 13.7
144.9 ± 15.2
94.5 ± 9.0
92.7 ± 9.9
Masseter
230.2 ± 22.7
209.6 ± 18.2
148.2 ± 14.7
134.0 ± 11.7
Suprahyoid
23.4 ± 1.2
22.4 ± 2.2
15.8 ± 1.3
15.4 ± 1.5
Sternocleidomastoid
24.3 ± 2.9
22.9 ± 3.5
15.3 ± 2.1
16.3 ± 1.8
Table 4: Myodynamic balance of maxillofacial muscles at the time of dental clenching at maximum effort
in 10- to 12-year-old children with physiological dental occlusion (RMS and ARV in μV).
38
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[39] =>
Myodynamic balance in children
fied and filtered (elimination of disturbances). The bioelectric signal is acquired, converted into digital form
and transmitted to the computer for real-time display
on the monitor.
The sEMG analysis was performed using the following
functional tests:
1. mandible in relative physiological rest state, that is,
teeth not in contact and lips just in contact (Fig. 1);
2. mandible in physiological position of occlusion, that
is, teeth in contact (Fig. 2); and
3. mandible in voluntary clenching to the maximum
effort (Fig. 3).
The main index of the functional state of a muscle
is the value of the amplitude of its biological potential.
Currently, 2 average amplitude indices, root mean
square (RMS) and average rectified value (ARV), are
mainly used. The maximum amplitude of the electromyographic signal is measured from the maximum
positive peak to the maximum negative peak. The individual measured values can be processed to obtain
the mean value of the absolute value with respect to
the period. This index is the mean value of the adjusted signal (ARV), and it is usually expressed in μV.4, 5
The RMS index represents the value of a continuous
voltage that develops a power equivalent to that of the
electromyographic signal (alternating voltage). This
index is calculated as the square root of the mean quadratic value of the electromyographic signal, and it is
expressed in μV. Most of the other indexes, calculated
according to the software, are derived from the ARV
and RMS amplitude indices. The following electromyographic indices4, 5 were analyzed:
–– RMS of biopotentials (expressed in μV);
–– ARV of biopotentials (expressed in μV);
–– total bioelectric activity (Total index, expressed
in μV): the sum of all the ARV or RMS indices related to the bioelectric activity of the right and left
muscles;
–– participation in the bioelectric activity by each
muscle in question expressed in % (calculated
according to both the ARV and RMS indices)—the
calculation of these participation indices was performed by dividing the bioelectric activity index of each
muscle (in ARV or RMS) for the total index and subsequently multiplying by 100; and
–– maximum amplitude of biopotentials index (Max;
expressed in μV).
The results of the present study were statistically
analyzed using BioStat software (AnalystSoft). An
α < 0.05 was used.
Results
Tables 1 and 2 show the sum parameters of the left
and right temporalis, masseter, suprahyoid and sternocleidomastoid muscles (Fig. 4). These parameters
have been taken from Table 3 for Table 1 and from
Table 4 for Table 2, respectively.
The data showed that, in 7- to 9-year-olds with physiological dental occlusion, the position of the mandible
at the time of voluntary clenching at maximum effort
can be normal only if the total value of the masticatory
muscles (RMS; temporalis and masseter) is within the
limits of 256.5 ± 9.0 μV on the right and 254.0 ± 7.3 μV
on the left, and of the suprahyoid (digastric) muscles
within 27.3 ± 3.2 μV on the right and 31.6 ± 3.7 μV
on the left. The ratio of the temporalis and masseter
muscles to the suprahyoid muscles was 9.4 times on
the right and 8.0 on the left for the RMS index, and
8.2 and 6.6 times, respectively, for the ARV index. It
should be noted that, in the case of normal posture,
the biopotentials of the sternocleidomastoid muscles
were within the limits of 23.4 ± 4.2 μV on the right and
19.7 ± 3.2 μV on the left.
The normal position of the jaw at the time of voluntary clenching at maximum effort in the 10- to 12-yearolds was possible when the total value of the temporalis and masseter muscles was within the limits of
374.8 ± 15.5 μV on the right and 354.0 ± 16.4 μV
on the left, of the suprahyoid muscles was within
23.4 ± 1.9 μV on the right and 22.4 ± 2.1 μV on the
left. The ratio of the temporalis and masseter muscles
to the suprahyoid muscles was 16.0 times on the right
and 15.8 times on the left for the RMS index, and 15.3
and 14.7 times, respectively, for the ARV index. In
the 10- to 12-year-olds in normal posture, the biopotentials of the sternocleidomastoid muscles were
within the limits of 24.3 ± 2.9 μV on the right and
22.9 ± 3.5 μV on the left. It should be noted that, in
both age groups, no reliable differences were found
between the parameters of the masseter, temporalis,
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
39
[40] =>
Myodynamic balance in children
Age
(years)
7–9
10–12
Coordination coefficient
Right
256.5 – 27.3
256.5 + 27.3
374.8 – 23.4
374.8 + 23.4
Left
=
=
229.2
283.8
351.4
398.2
= 0.81
= 0.88
254.0 – 31.6
254.0 + 31.6
354.0 – 22.4
354.0 + 22.4
=
=
224.4
285.6
331.6
376.4
= 0.78
= 0.88
Table 5: Coordination coefficient values in relation to the RMS index at the time of voluntary clenching
at maximum effort in children aged 7–9 and 10–12 years with physiological occlusion.
suprahyoid and sternocleidomastoid muscles on the
right and on the left, respectively.
Table 5 shows that the coordination coefficient for
the maxillofacial area muscles evaluated at the time
of voluntary clenching at maximum effort in the 7- to
9-year-olds was within the limits of 0.81 on the right
and 0.78 on the left. In the 10- to 12-year-olds, at the
end of the period of transition from primary dentition,
the coordination coefficient was higher compared with
the 7- to 9-year-olds, and it was the same (0.88) for
both sides. This indicates that, toward the end of the
replacement of the primary dentition, the muscles of
the maxillofacial area on the left and on the right work
in a homogeneous regimen.
100 %
TAD
MSTD
100 %
DIGD
100 %
Discussion
The present study evaluated the homogeneous muscular activity in the maxillofacial area and identified
myodynamic balance in children with physiological
dental occlusion. The mean biopotential values were
identified of the masseter, temporalis and suprahyoid
muscles, which participate directly in the retention of
the physiological position of the resting jaw at the time
of voluntary clenching at maximum effort. The mean
values of the biopotentials of the muscles were assessed, as was the muscular myodynamic balance on
the right and on the left. It was seen that the homogeneity of the muscular activity improves with age.
It is very important to establish the myodynamic
balance of the muscles of the maxillofacial area
between the right and left and compare them, since
they condition the normal position (normognatic) of the
jaw. In unbalanced conditions, the mandible may be
40
displaced either to the right or to the left, as well as
in a distal or mesial direction. In addition, to study the
myodynamic balance of the muscles of the maxillofacial area, it is necessary to have information on the
100 %
TAS
MSTS
100 %
DIGS
100 %
Fig. 5
homogeneous activity of the agonist and antagonist
muscles, both in physiological or pathological conditions.
The coordination coefficient provides a value that
expresses the balance of the muscles between the
right and left in rest position and at maximum clenching. The myodynamic equilibrium and homogeneous
muscular activity are illustrated in Figure 5, where the
parameters of the masseter, temporalis and suprahyoid muscles in children with physiological dental occlusion are considered to be entirely normal. The intensity
of the color changes according to the sEMG parameters and the deviation from the mean.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
[41] =>
Myodynamic balance in children
As mentioned before, previous studies on children
compared patients with diseases. However, in those
studies, the values in µV were assessed for dental
clenching with cotton rolls and expressed as percentages of maximum voluntary clenching. This means
that a direct comparison with the data from the present
study is difficult. However, it should be considered
that the use of cotton rolls during maximum clenching should increase the values in µV compared with
maximum clenching without cotton rolls. Nevertheless,
varying findings have been reported in several studies
performed in children. In a clinical study,8 for example,
the electromyographic activity and thickness of the
right masseter, left masseter, right temporalis and left
temporalis muscles and bite force in children with temporomandibular disorders were evaluated. The bite
force was lower in the temporomandibular disorders
group than in the control group. In another study,9 the
electromyographic activity of the masseter and anterior portion of the temporalis muscles was evaluated
in children with and without sleep bruxism. Children
with sleep bruxism showed no significant difference in
EMG of masticatory muscles at rest and in maximal
intercuspal positions of the mandible compared with
the control group.
In another study,10 the electromyographic activity of
the temporalis and masseter muscles was evaluated
in children with mixed dentition and a mean age of
8.6 years. All the children were undergoing rapid
maxillary expansion with a bonded rapid maxillary
expansion appliance. The electromyographic analysis
showed that the activity of the temporalis and masseter
muscles increased significantly when the expansion
appliance was removed. During dental clenching with
cotton rolls, the values in µV expressed as percentages of the maximum voluntary clenching increased
from ~ 112–113 µV to 143–149 µV for the masseter
muscles and from ~ 102 µV to 116–135 µV for the temporalis muscles. In the present study, in children with
physiological dental occlusion, the data were higher
during maximum voluntary clenching, 256.5 µV for the
temporalis and masseter muscles. This might indicate
that the removal of the rapid maxillary expansion appliance in the previously discussed study10 did not permit
normal myoelectric activity of these muscles.
In conclusion, the present study provided the range
of physiological function of the masticatory and ster-
nocleidomastoid muscles that children aged 7–9 and
10–12 should present in a myographic examination.
Any deviation from these values suggests the presence of occlusal and/or postural problems, and an appropriate intervention to reach the values indicated in
the present study should be considered.
Competing interests
The authors declare that they have no competing interests.
Legends
Fig. 1 – (A) Data acquired digitally and represented in
the form of tables and histograms. Signal evaluated
in relative physiological rest state. (B) Raw signal in
relative physiological rest state. (C1) Histogram representation of asymmetrical root mean square signals in
relative physiological rest state; (C2) signals normalized. (D) Further graphic representation of the mandible signals in relative physiological rest state.
Fig. 2 – (A) Representation in tables and histograms
of the signal in the physiological position of occlusion (teeth in contact). (B) Raw signal in physiological dental occlusion position (teeth in contact). (C1)
Histogram representation of asymmetrical root mean
square signals in physiological dental occlusion position (teeth in contact); (C2) signals normalized. (D)
Further graphic representation of the mandible signals
in physiological dental occlusion position (teeth in
contact).
Fig. 3 – (A) Representation in tables and histograms of
the signal in voluntary clenching at maximum effort.
(B) Raw signal in voluntary clenching at maximum
effort. (C1) Histogram representation of asymmetrical root mean square signals in voluntary clenching at
maximum effort; (C2) signals normalized. (D) Further
graphic representation of the mandible signals in voluntary clenching at maximum effort.
Fig. 4 – Summary representation in a histogram of the
functional tests performed.
Fig. 5 – Myodynamic
equilibrium and homogeneous
muscular activity. TAD = Right anterior temporalis;
TAS = Left anterior temporalis; MSTD = Right masseter; MSTS = Left masseter; DIGD = Right digastric; DIGS = Left digastric. The intensity of the color
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
41
[42] =>
Myodynamic balance in children
changes according to the sEMG parameters and the
deviation from the mean. In the present diagram, the
color intensity is 100% for each parameter.
References
1. Cram JR, Kasman GS, Holtz J. Introduction to
surface electromyography.
→ Gaithersburg (MD): Aspen; 1998. 408 p.
2. Gadotti IC, Bérin F, Biasotto-Gonalez D. Preliminary
rapport on head posture and muscle activity in subjects with Class I and II.
→ J Oral Rehabil.
2005 Nov;32(11):794–9.
3. Ferrario VF, Tartaglia GM, Galletta A, Grassi GP,
Sforza C. The influence of occlusion on jaw and neck
muscle activity: a surface EMG study in healthy young
adults.
→ J Oral Rehabil.
2006 May;33(5):341–8.
4. Moreno I, Sánchez T, Ardizone I, Aneiros F, Celemin
A. Electromyographic comparisons between clenching, swallowing and chewing in jaw muscles with
varying occlusal parameters.
→ Med Oral Patol Oral Cir Bucal.
2008 Mar 1;13(3):E207–13.
5. Cecílio FA, Regalo SC, Palinkas M, Issa JP,
Siéssere S, Hallak JE, Machado-de-Sousa JP, Semprini M. Ageing and surface EMG activity patterns of
masticatory muscles.
→ J Oral Rehabil.
2010 Apr;37(4):248–55.
6. Petrović D, Vujkov S, Petronijević B, Šarčev I, Stojanac I. Examination of the bioelectrical activity of the
masticatory muscles during Angle’s Class II division 2
therapy with an activator.
→ Vojnosanit Pregl.
2014 Dec;71(12):1116–22.
7. Nakakawaji K, Kodachi K, Sakamoto T, Harazaki M,
Isshiki Y. Correlation between facial patterns and function of the masticatory muscles in girls and women.
→ Bull Tokyo Dent Coll.
2002 May;43(2):51–9.
8. Díaz-Serrano KV, Dias TM, Vasconcelos P, Sousa
LG, Siéssere S, Regalo S, Palinkas M. Impact of
42
temporomandibular disorders on the stomatognathic
system in children.
→ Med Oral Patol Oral Cir Bucal.
2017 Nov 1;22(6):e723–e729. doi: 10.4317/
medoral.22000.
9. Lucas Bde L, Barbosa Tde S, Pereira LJ, Gavião MB,
Castelo PM. Electromyographic evaluation of masticatory muscles at rest and maximal intercuspal positions
of the mandible in children with sleep bruxism.
→ Eur Arch Paediatr Dent.
2014 Aug;15(4):269–74.
10. De Rossi M, De Rossi A, Hallak JE, Vitti M, Regalo
SC. Electromyographic evaluation in children having
rapid maxillary expansion.
→ Am J Orthod Dentofacial Orthop.
2009 Sep;136(3):355–60.
11. Andrade AS, Gavião MB, Derossi M, Gameiro GH.
Electromyographic activity and thickness of masticatory muscles in children with unilateral posterior crossbite.
→ Clin Anat.
2009 Mar;22(2):200–6.
12. Ueda HM, Miyamoto K, Saifuddin M, Ishizuka Y,
Tanne K. Masticatory muscle activity in children and
adults with different facial types.
→ Am J Orthod Dentofacial Orthop.
2000 Jul;118(1):63–8.
13. Negoro T, Briggs J, Plesh O, Nielsen I, McNeill C,
Miller AJ. Bruxing patterns in children compared to
intercuspal clenching and chewing as assessed with
dental models, electromyography, and incisor jaw
tracing: preliminary study.
→ ASDC J Dent Child.
1998 Nov–Dec;65(6):449–58, 438.
14. Persin LS. Functional characteristics of properly
masticatory muscles and temporomandibular joints
in children with normal and prognathic bite during the
period of substitution of deciduous dentition [master’s
thesis].
→ [Мoscow]: University of Moscow; 1974. 215 p.
15. Persin LS. Electrophysiological investigations of
the muscles in the maxillo-facial area and temporomandibular joints in children with normal and abnormal
(prognathic) bites during the period of substitution of
deciduous dentition [doctoral thesis].
→ [Мoscow]: University of Moscow; 1978. 207 p.
Journal of Oral Science & Rehabilitation | Volume 5 – Issue 2/2019
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Guidelines for authors
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