Journal of Oral Science & Rehabilitation No. 3, 2017
Editorial
/ About the Journal of Oral Science & Rehabilitation
/ Accuracy of computer-assisted template-based implant placement using a conventional impression and scan model or digital impression: A prelimi- nary report from a randomized controlled trial
/ Zero apicectomy in endodontic microsurgery
/ How can the tapered implant design influence bundle bone preservation: An experimental study in American Foxhound dogs
/ Improved fully digital workflow to rehabilitate an edentulous patient with an implant overdenture in 4 appointments: A case report
/ Thirteen-year follow-up of a cross-arch implant-supported fixed restoration in a patient with generalized aggressive periodontitis and parafunctional habits
/ Flap design: New perspectives in periapical surgery
/ Fourth MIS Global Conference
/ Guidelines for authors
/ Imprint — about the publisher
Array
(
[post_data] => WP_Post Object
(
[ID] => 72436
[post_author] => 0
[post_date] => 2017-09-25 08:41:45
[post_date_gmt] => 2017-09-25 08:41:45
[post_content] =>
[post_title] => Journal of Oral Science & Rehabilitation No. 3, 2017
[post_excerpt] =>
[post_status] => publish
[comment_status] => closed
[ping_status] => closed
[post_password] =>
[post_name] => journal-of-oral-science-rehabilitation-no-3-2017
[to_ping] =>
[pinged] =>
[post_modified] => 2024-10-23 09:53:30
[post_modified_gmt] => 2024-10-23 09:53:30
[post_content_filtered] =>
[post_parent] => 0
[guid] => https://e.dental-tribune.com/epaper/josr0317/
[menu_order] => 0
[post_type] => epaper
[post_mime_type] =>
[comment_count] => 0
[filter] => raw
)
[id] => 72436
[id_hash] => d66546dd595e673d999e32a74dc5181443901ad0d8ac3ae5caa6553743414f0b
[post_type] => epaper
[post_date] => 2017-09-25 08:41:45
[fields] => Array
(
[pdf] => Array
(
[ID] => 72437
[id] => 72437
[title] => JOSR0317.pdf
[filename] => JOSR0317.pdf
[filesize] => 0
[url] => https://e.dental-tribune.com/wp-content/uploads/JOSR0317.pdf
[link] => https://e.dental-tribune.com/epaper/journal-of-oral-science-rehabilitation-no-3-2017/josr0317-pdf-2/
[alt] =>
[author] => 0
[description] =>
[caption] =>
[name] => josr0317-pdf-2
[status] => inherit
[uploaded_to] => 72436
[date] => 2024-10-23 09:53:24
[modified] => 2024-10-23 09:53:24
[menu_order] => 0
[mime_type] => application/pdf
[type] => application
[subtype] => pdf
[icon] => https://e.dental-tribune.com/wp-includes/images/media/document.png
)
[cf_issue_name] => JOSR0317
[cf_edition_number] => 0317
[contents] => Array
(
[0] => Array
(
[from] => 03
[to] => 03
[title] => Editorial
[description] => Editorial
)
[1] => Array
(
[from] => 06
[to] => 07
[title] => About the Journal of Oral Science & Rehabilitation
[description] => About the Journal of Oral Science & Rehabilitation
)
[2] => Array
(
[from] => 08
[to] => 16
[title] => Accuracy of computer-assisted template-based implant placement using a conventional impression and scan model or digital impression: A prelimi- nary report from a randomized controlled trial
[description] => Accuracy of computer-assisted template-based implant placement using a conventional impression and scan model or digital impression: A prelimi- nary report from a randomized controlled trial
)
[3] => Array
(
[from] => 18
[to] => 26
[title] => Zero apicectomy in endodontic microsurgery
[description] => Zero apicectomy in endodontic microsurgery
)
[4] => Array
(
[from] => 28
[to] => 36
[title] => How can the tapered implant design influence bundle bone preservation: An experimental study in American Foxhound dogs
[description] => How can the tapered implant design influence bundle bone preservation: An experimental study in American Foxhound dogs
)
[5] => Array
(
[from] => 38
[to] => 46
[title] => Improved fully digital workflow to rehabilitate an edentulous patient with an implant overdenture in 4 appointments: A case report
[description] => Improved fully digital workflow to rehabilitate an edentulous patient with an implant overdenture in 4 appointments: A case report
)
[6] => Array
(
[from] => 48
[to] => 55
[title] => Thirteen-year follow-up of a cross-arch implant-supported fixed restoration in a patient with generalized aggressive periodontitis and parafunctional habits
[description] => Thirteen-year follow-up of a cross-arch implant-supported fixed restoration in a patient with generalized aggressive periodontitis and parafunctional habits
)
[7] => Array
(
[from] => 56
[to] => 61
[title] => Flap design: New perspectives in periapical surgery
[description] => Flap design: New perspectives in periapical surgery
)
[8] => Array
(
[from] => 62
[to] => 62
[title] => Fourth MIS Global Conference
[description] => Fourth MIS Global Conference
)
[9] => Array
(
[from] => 64
[to] => 64
[title] => Guidelines for authors
[description] => Guidelines for authors
)
[10] => Array
(
[from] => 66
[to] => 66
[title] => Imprint — about the publisher
[description] => Imprint — about the publisher
)
)
)
[permalink] => https://e.dental-tribune.com/epaper/journal-of-oral-science-rehabilitation-no-3-2017/
[post_title] => Journal of Oral Science & Rehabilitation No. 3, 2017
[client] =>
[client_slug] =>
[pages_generated] =>
[pages] => Array
(
[1] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-0.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-0.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-0.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-0.jpg
[1000] => 72436-5857287a/1000/page-0.jpg
[200] => 72436-5857287a/200/page-0.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[2] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-1.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-1.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-1.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-1.jpg
[1000] => 72436-5857287a/1000/page-1.jpg
[200] => 72436-5857287a/200/page-1.jpg
)
[ads] => Array
(
[0] => Array
(
[post_data] => WP_Post Object
(
[ID] => 72438
[post_author] => 0
[post_date] => 2024-10-23 09:53:24
[post_date_gmt] => 2024-10-23 09:53:24
[post_content] =>
[post_title] => epaper-72436-page-2-ad-72438
[post_excerpt] =>
[post_status] => publish
[comment_status] => closed
[ping_status] => closed
[post_password] =>
[post_name] => epaper-72436-page-2-ad-72438
[to_ping] =>
[pinged] =>
[post_modified] => 2024-10-23 09:53:24
[post_modified_gmt] => 2024-10-23 09:53:24
[post_content_filtered] =>
[post_parent] => 0
[guid] => https://e.dental-tribune.com/ad/epaper-72436-page-2-ad/
[menu_order] => 0
[post_type] => ad
[post_mime_type] =>
[comment_count] => 0
[filter] => raw
)
[id] => 72438
[id_hash] => 5940d71688444e3c29a0de652455dd27faf5f73d2266598cfc4bccbcf6ee3899
[post_type] => ad
[post_date] => 2024-10-23 09:53:24
[fields] => Array
(
[url] => http://intl.dental-tribune.com/company/mis-implants-technologies-ltd/
[link] => URL
)
[permalink] => https://e.dental-tribune.com/ad/epaper-72436-page-2-ad-72438/
[post_title] => epaper-72436-page-2-ad-72438
[post_status] => publish
[position] => 1.51,0.82,97.36,96.45
[belongs_to_epaper] => 72436
[page] => 2
[cached] => false
)
)
[html_content] =>
)
[3] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-2.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-2.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-2.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-2.jpg
[1000] => 72436-5857287a/1000/page-2.jpg
[200] => 72436-5857287a/200/page-2.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[4] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-3.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-3.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-3.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-3.jpg
[1000] => 72436-5857287a/1000/page-3.jpg
[200] => 72436-5857287a/200/page-3.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[5] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-4.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-4.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-4.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-4.jpg
[1000] => 72436-5857287a/1000/page-4.jpg
[200] => 72436-5857287a/200/page-4.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[6] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-5.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-5.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-5.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-5.jpg
[1000] => 72436-5857287a/1000/page-5.jpg
[200] => 72436-5857287a/200/page-5.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[7] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-6.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-6.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-6.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-6.jpg
[1000] => 72436-5857287a/1000/page-6.jpg
[200] => 72436-5857287a/200/page-6.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[8] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-7.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-7.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-7.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-7.jpg
[1000] => 72436-5857287a/1000/page-7.jpg
[200] => 72436-5857287a/200/page-7.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[9] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-8.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-8.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-8.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-8.jpg
[1000] => 72436-5857287a/1000/page-8.jpg
[200] => 72436-5857287a/200/page-8.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[10] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-9.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-9.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-9.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-9.jpg
[1000] => 72436-5857287a/1000/page-9.jpg
[200] => 72436-5857287a/200/page-9.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[11] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-10.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-10.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-10.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-10.jpg
[1000] => 72436-5857287a/1000/page-10.jpg
[200] => 72436-5857287a/200/page-10.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[12] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-11.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-11.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-11.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-11.jpg
[1000] => 72436-5857287a/1000/page-11.jpg
[200] => 72436-5857287a/200/page-11.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[13] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-12.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-12.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-12.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-12.jpg
[1000] => 72436-5857287a/1000/page-12.jpg
[200] => 72436-5857287a/200/page-12.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[14] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-13.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-13.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-13.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-13.jpg
[1000] => 72436-5857287a/1000/page-13.jpg
[200] => 72436-5857287a/200/page-13.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[15] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-14.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-14.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-14.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-14.jpg
[1000] => 72436-5857287a/1000/page-14.jpg
[200] => 72436-5857287a/200/page-14.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[16] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-15.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-15.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-15.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-15.jpg
[1000] => 72436-5857287a/1000/page-15.jpg
[200] => 72436-5857287a/200/page-15.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[17] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-16.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-16.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-16.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-16.jpg
[1000] => 72436-5857287a/1000/page-16.jpg
[200] => 72436-5857287a/200/page-16.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[18] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-17.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-17.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-17.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-17.jpg
[1000] => 72436-5857287a/1000/page-17.jpg
[200] => 72436-5857287a/200/page-17.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[19] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-18.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-18.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-18.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-18.jpg
[1000] => 72436-5857287a/1000/page-18.jpg
[200] => 72436-5857287a/200/page-18.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[20] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-19.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-19.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-19.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-19.jpg
[1000] => 72436-5857287a/1000/page-19.jpg
[200] => 72436-5857287a/200/page-19.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[21] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-20.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-20.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-20.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-20.jpg
[1000] => 72436-5857287a/1000/page-20.jpg
[200] => 72436-5857287a/200/page-20.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[22] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-21.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-21.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-21.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-21.jpg
[1000] => 72436-5857287a/1000/page-21.jpg
[200] => 72436-5857287a/200/page-21.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[23] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-22.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-22.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-22.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-22.jpg
[1000] => 72436-5857287a/1000/page-22.jpg
[200] => 72436-5857287a/200/page-22.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[24] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-23.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-23.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-23.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-23.jpg
[1000] => 72436-5857287a/1000/page-23.jpg
[200] => 72436-5857287a/200/page-23.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[25] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-24.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-24.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-24.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-24.jpg
[1000] => 72436-5857287a/1000/page-24.jpg
[200] => 72436-5857287a/200/page-24.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[26] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-25.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-25.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-25.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-25.jpg
[1000] => 72436-5857287a/1000/page-25.jpg
[200] => 72436-5857287a/200/page-25.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[27] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-26.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-26.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-26.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-26.jpg
[1000] => 72436-5857287a/1000/page-26.jpg
[200] => 72436-5857287a/200/page-26.jpg
)
[ads] => Array
(
[0] => Array
(
[post_data] => WP_Post Object
(
[ID] => 72439
[post_author] => 0
[post_date] => 2024-10-23 09:53:24
[post_date_gmt] => 2024-10-23 09:53:24
[post_content] =>
[post_title] => epaper-72436-page-27-ad-72439
[post_excerpt] =>
[post_status] => publish
[comment_status] => closed
[ping_status] => closed
[post_password] =>
[post_name] => epaper-72436-page-27-ad-72439
[to_ping] =>
[pinged] =>
[post_modified] => 2024-10-23 09:53:24
[post_modified_gmt] => 2024-10-23 09:53:24
[post_content_filtered] =>
[post_parent] => 0
[guid] => https://e.dental-tribune.com/ad/epaper-72436-page-27-ad/
[menu_order] => 0
[post_type] => ad
[post_mime_type] =>
[comment_count] => 0
[filter] => raw
)
[id] => 72439
[id_hash] => 5ada1c5c3f839525776e8cd2c138c5e98f6ddc03c66268964b5e37f20c8f5c81
[post_type] => ad
[post_date] => 2024-10-23 09:53:24
[fields] => Array
(
[url] => http://www.dental-tribune.com/articles/index/scope/news/region/international
[link] => URL
)
[permalink] => https://e.dental-tribune.com/ad/epaper-72436-page-27-ad-72439/
[post_title] => epaper-72436-page-27-ad-72439
[post_status] => publish
[position] => 0.73,1.37,98.14,48.63
[belongs_to_epaper] => 72436
[page] => 27
[cached] => false
)
)
[html_content] =>
)
[28] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-27.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-27.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-27.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-27.jpg
[1000] => 72436-5857287a/1000/page-27.jpg
[200] => 72436-5857287a/200/page-27.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[29] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-28.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-28.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-28.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-28.jpg
[1000] => 72436-5857287a/1000/page-28.jpg
[200] => 72436-5857287a/200/page-28.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[30] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-29.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-29.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-29.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-29.jpg
[1000] => 72436-5857287a/1000/page-29.jpg
[200] => 72436-5857287a/200/page-29.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[31] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-30.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-30.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-30.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-30.jpg
[1000] => 72436-5857287a/1000/page-30.jpg
[200] => 72436-5857287a/200/page-30.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[32] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-31.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-31.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-31.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-31.jpg
[1000] => 72436-5857287a/1000/page-31.jpg
[200] => 72436-5857287a/200/page-31.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[33] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-32.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-32.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-32.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-32.jpg
[1000] => 72436-5857287a/1000/page-32.jpg
[200] => 72436-5857287a/200/page-32.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[34] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-33.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-33.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-33.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-33.jpg
[1000] => 72436-5857287a/1000/page-33.jpg
[200] => 72436-5857287a/200/page-33.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[35] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-34.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-34.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-34.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-34.jpg
[1000] => 72436-5857287a/1000/page-34.jpg
[200] => 72436-5857287a/200/page-34.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[36] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-35.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-35.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-35.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-35.jpg
[1000] => 72436-5857287a/1000/page-35.jpg
[200] => 72436-5857287a/200/page-35.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[37] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-36.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-36.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-36.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-36.jpg
[1000] => 72436-5857287a/1000/page-36.jpg
[200] => 72436-5857287a/200/page-36.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[38] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-37.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-37.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-37.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-37.jpg
[1000] => 72436-5857287a/1000/page-37.jpg
[200] => 72436-5857287a/200/page-37.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[39] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-38.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-38.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-38.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-38.jpg
[1000] => 72436-5857287a/1000/page-38.jpg
[200] => 72436-5857287a/200/page-38.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[40] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-39.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-39.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-39.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-39.jpg
[1000] => 72436-5857287a/1000/page-39.jpg
[200] => 72436-5857287a/200/page-39.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[41] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-40.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-40.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-40.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-40.jpg
[1000] => 72436-5857287a/1000/page-40.jpg
[200] => 72436-5857287a/200/page-40.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[42] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-41.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-41.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-41.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-41.jpg
[1000] => 72436-5857287a/1000/page-41.jpg
[200] => 72436-5857287a/200/page-41.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[43] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-42.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-42.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-42.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-42.jpg
[1000] => 72436-5857287a/1000/page-42.jpg
[200] => 72436-5857287a/200/page-42.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[44] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-43.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-43.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-43.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-43.jpg
[1000] => 72436-5857287a/1000/page-43.jpg
[200] => 72436-5857287a/200/page-43.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[45] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-44.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-44.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-44.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-44.jpg
[1000] => 72436-5857287a/1000/page-44.jpg
[200] => 72436-5857287a/200/page-44.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[46] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-45.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-45.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-45.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-45.jpg
[1000] => 72436-5857287a/1000/page-45.jpg
[200] => 72436-5857287a/200/page-45.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[47] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-46.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-46.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-46.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-46.jpg
[1000] => 72436-5857287a/1000/page-46.jpg
[200] => 72436-5857287a/200/page-46.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[48] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-47.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-47.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-47.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-47.jpg
[1000] => 72436-5857287a/1000/page-47.jpg
[200] => 72436-5857287a/200/page-47.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[49] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-48.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-48.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-48.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-48.jpg
[1000] => 72436-5857287a/1000/page-48.jpg
[200] => 72436-5857287a/200/page-48.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[50] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-49.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-49.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-49.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-49.jpg
[1000] => 72436-5857287a/1000/page-49.jpg
[200] => 72436-5857287a/200/page-49.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[51] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-50.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-50.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-50.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-50.jpg
[1000] => 72436-5857287a/1000/page-50.jpg
[200] => 72436-5857287a/200/page-50.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[52] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-51.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-51.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-51.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-51.jpg
[1000] => 72436-5857287a/1000/page-51.jpg
[200] => 72436-5857287a/200/page-51.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[53] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-52.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-52.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-52.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-52.jpg
[1000] => 72436-5857287a/1000/page-52.jpg
[200] => 72436-5857287a/200/page-52.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[54] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-53.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-53.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-53.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-53.jpg
[1000] => 72436-5857287a/1000/page-53.jpg
[200] => 72436-5857287a/200/page-53.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[55] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-54.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-54.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-54.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-54.jpg
[1000] => 72436-5857287a/1000/page-54.jpg
[200] => 72436-5857287a/200/page-54.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[56] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-55.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-55.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-55.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-55.jpg
[1000] => 72436-5857287a/1000/page-55.jpg
[200] => 72436-5857287a/200/page-55.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[57] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-56.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-56.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-56.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-56.jpg
[1000] => 72436-5857287a/1000/page-56.jpg
[200] => 72436-5857287a/200/page-56.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[58] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-57.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-57.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-57.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-57.jpg
[1000] => 72436-5857287a/1000/page-57.jpg
[200] => 72436-5857287a/200/page-57.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[59] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-58.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-58.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-58.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-58.jpg
[1000] => 72436-5857287a/1000/page-58.jpg
[200] => 72436-5857287a/200/page-58.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[60] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-59.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-59.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-59.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-59.jpg
[1000] => 72436-5857287a/1000/page-59.jpg
[200] => 72436-5857287a/200/page-59.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[61] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-60.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-60.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-60.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-60.jpg
[1000] => 72436-5857287a/1000/page-60.jpg
[200] => 72436-5857287a/200/page-60.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[62] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-61.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-61.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-61.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-61.jpg
[1000] => 72436-5857287a/1000/page-61.jpg
[200] => 72436-5857287a/200/page-61.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[63] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-62.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-62.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-62.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-62.jpg
[1000] => 72436-5857287a/1000/page-62.jpg
[200] => 72436-5857287a/200/page-62.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[64] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-63.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-63.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-63.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-63.jpg
[1000] => 72436-5857287a/1000/page-63.jpg
[200] => 72436-5857287a/200/page-63.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[65] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-64.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-64.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-64.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-64.jpg
[1000] => 72436-5857287a/1000/page-64.jpg
[200] => 72436-5857287a/200/page-64.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[66] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-65.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-65.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-65.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-65.jpg
[1000] => 72436-5857287a/1000/page-65.jpg
[200] => 72436-5857287a/200/page-65.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[67] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-66.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-66.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-66.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-66.jpg
[1000] => 72436-5857287a/1000/page-66.jpg
[200] => 72436-5857287a/200/page-66.jpg
)
[ads] => Array
(
)
[html_content] =>
)
[68] => Array
(
[image_url] => Array
(
[2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/2000/page-67.jpg
[1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/1000/page-67.jpg
[200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/200/page-67.jpg
)
[key] => Array
(
[2000] => 72436-5857287a/2000/page-67.jpg
[1000] => 72436-5857287a/1000/page-67.jpg
[200] => 72436-5857287a/200/page-67.jpg
)
[ads] => Array
(
)
[html_content] =>
)
)
[pdf_filetime] => 1729677204
[s3_key] => 72436-5857287a
[pdf] => JOSR0317.pdf
[pdf_location_url] => https://e.dental-tribune.com/tmp/dental-tribune-com/72436/JOSR0317.pdf
[pdf_location_local] => /var/www/vhosts/e.dental-tribune.com/httpdocs/tmp/dental-tribune-com/72436/JOSR0317.pdf
[should_regen_pages] => 1
[pdf_url] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/72436-5857287a/epaper.pdf
[pages_text] => Array
(
[1] =>
Journal of
Oral Science
&
Rehabilitation
I S S N 2 3 6 5 - 6 8 9 1 (Online)
Volume 3 — Issue 3/2017
I S S N 2 3 6 5 - 6 1 2 3 (Print)
Journal for periodontology, implant dentistry,
dental prosthodontics and maxillofacial surgery
[2] =>
© MIS Implants Technologies Ltd. All rights reserved.
RADISE ISLA
A
P
U
ND,
SSA
BA
A
N
HA
Y
MA
G
O
L
2,
1.0
8-1
S,
8
201
360°
IMP
LA
NT
O
GLOBAL
CONFERENCE 2018
LEARN THE EASY WAY. MAKE IT SIMPLE
MIS is pleased and honored to invite you to the 4th MIS Global Conference:
360 IMPLANTOLOGY, in beautiful Nassau Paradise Island, Bahamas. This Global
IH@?L?H=?PCFF>?FCO?L;HCHM?HÉ?;H>NH@ILA?MM;
[3] =>
Editorial
Journal of
Oral Science
&
Rehabilitation
New perspectives in periapical surgery
Periapical surgery has long been performed in patients with periapical disorders. The massive introduction of dental implants in dental practice has not displaced periapical surgery, which remains
the first treatment option in the case of teeth amenable to recovery and is preferable to implant
placement.
A new scenario has emerged in periapical surgery with the introduction of novel retrograde filler
materials, finer and more precise surgical instruments, and endoscopic and microscopic surgical
field illumination and magnification. In effect, it is now possible to eliminate the periapical lesion
while preserving the causal tooth, with high long-term success rates.
Despite this, however, there is a notorious lack of clinical documentation on periapical surgery presented at courses and congresses and published in scientific journals compared with the cornerstone
in dental practice today: implantology.
It is worth knowing that, in many cases, teeth that are to be removed and replaced with implants
could in fact be preserved. In this regard, the technical advances in periapical surgery are able to
improve the quality of life of our patients and help them keep their teeth.
Dr. Miguel Peñarrocha Diago
Co-Editor
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017
03
[4] =>
Content
03
Editorial
Dr. Miguel Peñarrocha Diago
06
About the Journal of Oral Science & Rehabilitation
08
Marco Tallarico et al.
Accuracy of computer-assisted template-based implant placement using
a conventional impression and scan model or digital impression: A preliminary report from a randomized controlled trial
18
Randa Harik et al.
Zero apicectomy in endodontic microsurgery
28
José Luis Calvo Guirado et al.
How can the tapered implant design influence bundle bone preservation:
An experimental study in American Foxhound dogs
38
Marco Tallarico et al.
Improved fully digital workflow to rehabilitate an edentulous patient
with an implant overdenture in 4 appointments: A case report
48
David French & Erta Xhanari
Thirteen-year follow-up of a cross-arch implant-supported fixed
restoration in a patient with generalized aggressive periodontitis and
parafunctional habits
56
Maria Peñarrocha Diago et al.
Flap design: New perspectives in periapical surgery
62
Fourth MIS Global Conference
64
Guidelines for authors
66
Imprint — about the publisher
04 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[5] =>
ETIII NH IMPLANT
The Hiossen ETIII NH Implant features a super-hydrophilic
Sandblasted and Acid-etched (SA) surface combined with
a unique bio-absorbable apatite Nano Coating that
helps ensure optimal treatment outcomes with every
implant you place.
• Enhanced blood affinity and platelet adhesion
• Excellent cell response and initial stability
• 39% improvement in bone-to-implant contact
• Higher success rate in poor quality bone
• Improved osseointegration decreases treatment
period by over 30%
To learn more, visit hiossen.com
or call 888.678.0001
NH Surface
Untreated Surface
Both implants were dipped in animal blood for one minute
Made in the USA
[6] =>
About
About
the Journal of Oral Science & Rehabilitation
The aim of the Journal of Oral Science & Rehabilitation is to promote rapid
communication of scientific information between academia, industry
and dental practitioners, thereby influencing the decision-making in
clinical practice on an international level.
The Journal of Oral Science & Rehabilitation publishes original and highquality research and clinical papers in the fields of periodontology, implant dentistry, prosthodontics and maxillofacial surgery. Priority is
given to papers focusing on clinical techniques and with a direct impact
on clinical decision-making and outcomes in the above-mentioned
fields. Furthermore, book reviews, summaries and abstracts of scientific
meetings are published in the journal.
Papers submitted to the Journal of Oral Science & Rehabilitation are subject to rigorous double-blind peer review. Papers are initially screened for
relevance to the scope of the journal, as well as for scientific content and
quality. Once accepted, the manuscript is sent to the relevant associate
editors and reviewers of the journal for peer review. It is then returned to
the author for revision and thereafter submitted for copy editing. The
decision of the editor-in-chief is made after the review process and is
considered final.
About
Dental Tribune Science
Dental Tribune Science (DT Science) is an online open-access publishing
platform (www.dtscience.com) on which the Journal of Oral Science &
Rehabilitation is hosted and published.
DT Science is a project of the Dental Tribune International Publishing
Group (DTI). DTI is composed of the leading dental trade publishers
around the world. For more, visit
www.dental-tribune.com
06 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[7] =>
About
Benefits
of publishing in the journal for authors
There are numerous advantages of publishing in the Journal of Oral
Science & Rehabilitation:
– Accepted papers are published in print and as e-papers on
www.dtscience.com.
– Authors’ work is granted exposure to a wide readership, ensuring
increased impact of their research through open-access publishing on
www.dtscience.com.
– Authors have the opportunity to present and promote their
research by way of interviews and articles published on both
www.dtscience.com and www.dental-tribune.com.
– Authors can also post videos relating to their research, present
a webinar and blog on 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 3 | Issue 3/2017
07
[8] =>
Accuracy of computer-assisted implant placement
Accuracy of computer-assisted templatebased implant placement using a
conventional impression and scan model
or digital impression: A preliminary
report from a randomized controlled trial
Abstract
Objective
Marco Tallarico,a Erta Xhanari,b Fabio Cocchi,c
Luigi Canullo,d Franco Schipanie & Silvio Mario Melonif
a
Aldent University, Tirana, Albania; private practice,
Rome, Italy
b
Aldent University, Tirana, Albania; private practice,
Tirana, Albania
c
Private practice, Modena, Italy
d
Private practice, Rome, Italy
e
Private practice, Bologna, Italy
f
Surgical, micro-surgical and medical science
department, University of Sassari, Sassari, Italy;
private practice, Arzachena, Italy
Corresponding author:
Dr. Marco Tallarico
Via di Val Tellina, 116
00151 Rome
Italy
me@studiomarcotallarico.it
How to cite this article:
Tallarico M, Xhanari E, Cocchi F, Canullo L, Schipani F,
Meloni SM. Accuracy of computer-assisted
template-based implant placement using a conventional
impression and scan model or digital impression:
A preliminary report from a randomized controlled trial.
J Oral Science Rehabilitation.
2017 Sep;3(3):08–16.
08 Volume 3 | Issue 3/2017
The objective of this study was to compare implant survival rate, templaterelated complications and virtual planning accuracy of computer-assisted
template-based implant placement using a conventional impression and
scan model or digital impression to rehabilitate partially edentulous
patients using flapless or miniflap procedures and immediate loading.
Materials and methods
Any partially edentulous patients requiring at least one implant, to be
planned on the basis of cone beam computed tomography (CBCT) scans
using dedicated software, were enrolled in the trial. Patients were randomized according to a parallel-group design into two arms: intraoral
digital impression (fully digital group) versus conventional impression
and scan model (control group). Implants were to be placed flapless and
loaded immediately, if inserted with a torque over 35 N cm, with reinforced provisional prostheses. Three deviation parameters (horizontal,
vertical and angular) were defined and calculated between the planned
and placed implant positions and analyzed statistically. Results were
compared using a mixed-design repeated-measures analysis of variance
model (ʸ = 0.05).
Results
Twelve patients were randomized to the fully digital group (6 patients
with 17 implants) and control group (6 patients with 20 implants). The
mean error in angle was 2.56 ± 1.52° (range: 0.3–5.0°) in the fully digital
group and 2.18 ± 1.41° (range: 0.3–5.8°) in the control group (P = 0.519).
In the horizontal plane (mesiodistal), the mean error was 0.57 ± 0.32 mm
(range: 0.1–1.1 mm) in the fully digital group and 0.43 ± 0.26 mm (range:
0.1–0.9 mm) in the control group (P = 0.249). In the vertical plane (apicocoronal), the mean error was 0.67 ± 0.51 mm (range: 0.0–1.6 mm) in the
fully digital group and 0.43 ± 0.32 mm (range: 0.0–1.2 mm) in the control
group (P = 0.180).
Journal of
Oral Science & Rehabilitation
[9] =>
Accuracy of computer-assisted implant placement
Conclusion
Within the limitations of the present randomized controlled trial, it was
found that intraoral digital impressions may be a viable alternative to
conventional impressions and scan models for the rehabilitation of partially edentulous patients using computer-guided template-assisted
implant placement.
Keywords
Intraoral scanner, digital impression, guided surgery, accuracy, dental
implants.
Introduction
Proper implant position has a significant impact
on the esthetic and functional outcomes of
implant-supported restorations.1, 2 Therefore,
the implant must be placed accurately according
to the treatment plan. Computer-assisted
template-based implant placement (guided surgery) has become increasingly popular owing to
improved planning and the higher transfer accuracy of the virtual plan to the surgical site compared with freehand insertion or freehand final
drilling.3 Hence, it has undoubtedly been a major
achievement to provide optimal 3-D implant
positioning with respect to both anatomical and
prosthetic parameters, as well as higher patient
satisfaction.4
A recently published meta-analysis of in vitro
and in vivo studies found a total mean error of
1.12 mm at the entry point and 1.39 mm at the
apex. 5 The accuracy of computer-assisted
template-based implant placement depends on
several factors, from data set acquisition to the
surgical procedure. Originally, guided surgery
protocols advocated a dual-scan protocol.6 In
recent years, new technologies combining data
from computed tomography (CT) or cone beam
computed tomography (CBCT) images with
information on the soft tissue and crown
morphology have been developed. Dedicated
software allows for accurate virtual implant
planning, always based on the prosthetic volume
of the teeth to be rehabilitated and making
immediate loading easier.4, 7–9 Surgical guides
may be produced by computer-aided design/
computer-aided manufacture technology, such
as stereolithography, manually in a dental laboratory or by high-resolution 3-D printer. Finally,
irrespective of the method of manufacture, the
optimal fit of the surgical template and its
stabilization are essential to accurately transfer
the virtual implant position to the patient’s
mouth.
Digital impressions replace the need for conventional materials that can be inconvenient and
messy for patients. Today, there is no doubt
about the potential of recent intraoral optical
impression systems available on the market as
regards diagnosis and the treatment plan. Particularly noteworthy is the complete integration
with other digital technologies to provide for
accurate and faster patient-centered health
solutions.10, 11 Nevertheless, to the best of our
knowledge, at the time of writing this article,
there were no other published randomized clinical trials evaluating a fully digital approach to
computer-assisted template-based implant
placement.
The aim of the present study was to compare
implant survival rate, template-related complications and virtual planning accuracy of
computer-assisted template-based implant
placement using a conventional impression and
scan model or digital impression. The null
hypothesis was that there would be no difference between these interventions. This trial is
reported in accordance with the CONSORT
Statement for improving the quality of reporting
of parallel-group randomized trials.12
Materials and methods
This study was designed as a randomized controlled trial of parallel-group design conducted
at a private center in Rome, between May 2016
and March 2017. Surgical and prosthetic procedures were performed by one expert clinician
(MT). To the best of our knowledge, at the time of
writing this article, there were no other similar
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 09
[10] =>
Accuracy of computer-assisted implant placement
Fig. 1
Fig. 1
Intraoral digital impression
in the fully digital group.
Fig. 2
Conventional impression,
wax-up and scan model in
the control group.
studies, not allowing for a true sample size
calculation. Hence, it was decided to publish
preliminary results with 12 patients.
Partially edentulous patient aged 18 years
or older, able to sign an informed consent form
and in need of an implant-supported fixed restoration was considered eligible for this study.
Any potential implant locations based on individual patient requirements were considered
eligible in the present trial. No set location or
group of locations was excluded.
Patients were not admitted to the study if
any of the following exclusion criteria were
present: general medical contraindication to
oral surgery (American Society of Anesthesiologists [ASA] Physical Status Class III or IV),
irradiation of the head and neck area less than
1 year before implantation, psychiatric problems, alcohol or drug abuse, pregnant or nursing, untreated periodontitis, severe bruxism or
clenching, uncontrolled diabetes, poor oral
hygiene and motivation, and inability to complete the follow-up. The investigation was conducted according to the principles embodied in
the Declaration of Helsinki of 1975 for biomedical research involving human subjects, as
revised in 2008. All of the patients were
informed about the nature of the treatment and
their written consent was obtained. Data collection was designed to preserve patient anonymity.
All of the patients received preoperative
photographs, periapical radiographs or panoramic radiographs for initial screening and
evaluation. The prosthetic-driven planning
workflow started with taking a CBCT scan
(CRANEX 3Dx, SOREDEX, Tuusula, Finland) of
the enrolled patient, using a wax bite to separate
10 Volume 3 | Issue 3/2017
Fig. 2
the dental arches. The next step was to create
a digital model, accomplished in two ways: the
clinician used an intraoral scanner to create a
digital impression (Fig. 1), or the clinician took
a conventional impression and then scanned the
impression using an extraoral scanner (Fig. 2).
Patients were randomly assigned to undergo
intraoral digital impressions (fully digital group)
or conventional impressions (control group). In
the fully digital group, a digital impression
was taken using a CS 3600 intraoral scanner
(Carestream Dental, Atlanta, Ga., U.S.). The digital data (STL interface format) were imported
into 3-D design software (exocad DentalCAD,
exocad, Darmstadt, Germany) to realize a virtual
wax-up according to the functional and esthetic
requirements. In the control group, a polyether
impression (Impregum, 3M ESPE, Seefeld,
Germany) was taken with a customized tray
(Diatray Top, Dental Kontor, Stockelsdorf,
Germany). The impressions were poured with
Type IV Gypsum (T6, Techim Group, Arese, Italy)
and then the models were mounted in a fully
adjustable articulator (PROTARevo 7, KaVo
Dental, Biberach, Germany). Afterward, a dental
wax-up was produced according to the functional and esthetic requirements. Finally, the
master cast and wax-up were digitalized using
a laboratory scanner (Sinergia-Scan, Version
2016 Plus, Nobil-Metal, Villafranca d’Asti, Italy).
In both groups, the STL and DICOM data
were imported into a 3-D software planning
program (3Diagnosys, Version 4.2, 3DIEMME,
Cantù, Italy). Then, the reprocessed surface
extrapolated from the DICOM data (using a
Hounsfield scale filter) and the surface generated by the master cast scanning process or by
the intraoral scanning process were merged
Journal of
Oral Science & Rehabilitation
[11] =>
Accuracy of computer-assisted implant placement
Fig. 3
using the software’s best-fitting repositioning
tools. At this point, the size and location of prosthetic-driven implants/abutments were
planned, taking into account the bone quality/
quantity, soft-tissue thickness, anatomical landmarks, and the type, volume and shape of the
final restoration (Fig. 3). After careful functional
and esthetic evaluation and final verification,
the prosthetic-driven plan was approved, and a
stereolithographic surgical template was fabricated with a newer rapid prototyping technology (New Ancorvis, Bologna, Italy).
One hour before implant placement, all of
the patients underwent professional oral
hygiene, used a prophylactic antiseptic containing 0.2% chlorhexidine (CURASEPT, Curaden
Healthcare, Saronno, Italy) for 1 min and received
prophylactic antibiotic therapy (2 g of amoxicillin
or 600 mg of clindamycin if allergic to penicillin).
In the control group, the accurate fit of the surgical templates was tried on the master model
and tested in the patient’s mouth, while in the
fully guided group, the fit of the surgical template was tried directly in the patient’s mouth
to fit (Fit Checker, GC, Tokyo, Japan). All of the
patients were treated under local anesthesia
using articaine with 1:100,000 epinephrine,
administered 20 min before surgery. The surgical
template was stabilized in relation to the opposing arch using a silicone surgical index, derived
from the mounted casts (control group) or from
the virtual plane (fully guided group), and two
to four preplanned anchor pins.
Hopeless teeth were extracted after implant
placement in order to improve the stability of
the surgical template and to align the pre- and
post-surgical scans. In the case of immediate
post-extractive implants, residual teeth were
extracted as atraumatically as possible immediately before surgery. Residual gaps were filled
using a synthetic hydroxyapatite enriched
with magnesium (SINTlife, Finceramica, Faenza,
Italy) or with beta-tricalcium phosphate
(Q-Oss+, Osstem, Seoul, South Korea). Sinus lift
procedures were performed using minimally
invasive transcrestal sinus floor elevation
(Crestal Approach Sinus KIT, CAS-KIT, Osstem).12
The bone graft material was based on autogenous bone collected at the implant site, combined with a synthetic hydroxyapatite enriched
with magnesium (SINTlife) or with betatricalcium phosphate (Q-Oss+).
Planned implants (Osstem TSIII, Osstem)
were placed flapless or with a minimally invasive flap using dedicate drills (OsstemGuide Kit
[Taper], Osstem), according to a fully guided
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 11
Fig. 3
Merging of CBCT, DICOM
and STL files. Frontal and
cross-sectional views of
virtual implant planning
used to create the surgical
templates.
[12] =>
Accuracy of computer-assisted implant placement
Fig. 4
Fig. 4
Dental panoramic tomogram
taken 1 year after loading.
Fig. 5
Frontal photograph taken
1 year after loading.
Fig. 5
protocol. Implant sites were prepared based on – Template-related complications: limited
the bone density evaluated by the surgeon at
access in posterior areas; buccal bony dehisthe first drilling. In the case of poor bone density,
cence (due to a mismatch of the surgical tem12
the implant site was underprepared. All of the
plate), evaluated by sounding the implant site
implants were inserted with a minimum inserwith a periodontal probe (PCPUNC156,
tion torque of 35 Ncm and were immediately
Hu-Friedy Italy, Milan, Italy) before implant
loaded at implant or abutment level. Any flaps
placement; insertion of a different implant
were then sutured with Vicryl 4-0 sutures
than planned and fracture of the surgical tem(Ethicon J&J International, Sint-Stevensplate. All of the complications were recorded
Woluwe, Belgium). The prefabricated tempoduring follow-up by the same clinician (MT),
rary acrylic restorations were trimmed and
who performed all of the surgical procedures.
polished chairside. Single restorations received – Accuracy: Three deviation parameters (horia nonoccluding occlusal scheme. Multiple-unit
zontal, vertical and angular) were defined and
implant-supported temporary restorations
calculated between the planned and placed
were splinted together and reinforced using a
implant positions (Fig. 6). The postoperative
metal framework.
STL file, derived from the intraoral scan
Immediately after implant placement,
(Fig. 7), was geometrically aligned with the
patients of both groups received a digital
files exported from the planning, by autoimpression (CS 3600), taken at implant level
mated image registration using maximization
using dedicate abutments (Type AQ scan
of mutual information (Dental SCAN, Version 6,
body, New Ancorvis), to check the position of
Open Technologies, Brescia, Italy; Figs. 8 & 9).
the placed implants. Afterwards, all of the
The horizontal (lateral), vertical (depth) and
patients received oral and written recommenangular deviations between virtual and placed
dations about medication, oral hygiene mainimplants was calculated along the long axis of
tenance and diet. Any sutures were removed
each implant. An expert engineer (FC) perfor10–14 days later, after local cleaning using an
med all of the measurements.
antiseptic agent (0. 2% chlorhexidine,
CURASEPT, Curaden). Patients were followed
Randomization
monthly for up to one year after implant
placement (Figs. 4 & 5).
One computer-generated restricted randomization list was created. Only one of the investigaOutcome measurements
tors, not involved in the selection and treatment
of the patients, was aware of the randomization
– Early implant failure: An implant was consid- sequence and had access to the randomization
ered to be a failure if it was lost owing to mobil- lists stored in a password-protected portable
ity, implant fracture and/or any infection computer. The random codes were enclosed in
requiring implant removal. The stability of sequentially numbered, identical, opaque sealed
each implant was measured manually with a envelopes. Envelopes were opened sequentially
torque of 25 N cm at delivery of the final resto- after eligible patients signed the informed conration and later with the prosthesis removed, sent forms; therefore, treatment allocation was
if needed (infection, extensive periapical bone concealed from the investigators in charge of
loss, mucosal inflammation).
enrolling and treating the patients.
12 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[13] =>
Accuracy of computer-assisted implant placement
Fig. 6
Schematic diagram of
the measurement of
deviations between planned
and placed implants.
Fig. 6
Fig. 7
Postoperative intraoral digital
impression.
Fig. 7
Statistical analysis
Patient data were collected in a Numbers
spreadsheet (Version 3.6.1 for Mac OS X 10.11.4).
A biostatistician with expertise in dentistry analyzed the data using SPSS software (IBM SPSS
Statistics for Macintosh, Version 22.0, IBM,
Armonk, N.Y., U.S.) for statistical analysis.
Descriptive analysis was performed for numeric
parameters using mean ± standard deviation
and median with a 95% confidence interval.
Template-related complications between the
two groups were compared using the Fisher
exact probability test. The mean differences in
the overall deviation in the clinical outcomes
compared with the virtual plan were compared
between groups using a mixed-design repeatedmeasures analysis of variance model. All statistical comparisons were conducted with a P value
set at 0.05.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 13
[14] =>
Accuracy of computer-assisted implant placement
Fig. 8
Fig. 9
Fig. 8
Schematic diagram of the
superimposition of
virtual planning (gray) and
the STL file derived from
the intraoral impression (red).
Fig. 9
Three-dimensional
superimposition of planned
and placed implants.
Fig. 10
Fig. 10
Maximum angular deviation
calculated according to the
implant diameter and length.
Results
Preliminary data from the 12 patients were
included in the present study. Patients were
randomized to the fully digital group (6 patients
with 17 implants) and control group (6 patients
with 20 implants). All of the implants were
14 Volume 3 | Issue 3/2017
inserted according to the manufacturer’s
instructions, with an insertion torque ranging
between 35 and 45 N cm. Overall, the analysis
of the final accuracy found a total mean error of
2.34 ± 1.44° (range: 0.3–5.8°) in angle,
0.49 ± 0.29 mm (range: 0.1–1.1 mm) in the horizontal plane (mesiodistal) and 0.53 ± 0.42 mm
Journal of
Oral Science & Rehabilitation
[15] =>
Accuracy of computer-assisted implant placement
(range: 0.0–1.6 mm) in the vertical plane
(apico-coronal). All the measurements were
within the safety margins of the software. In all
the three measures, there were no statistically
significant differences between fully digital and
conventional impressions. The mean error in
angle was 2.56 ± 1.52° (range: 0.3–5.0°) in the
fully digital group and 2.18 ± 1.41° (range: 0.3–
5.8°) in the control group (P = 0.519). In the horizontal plane (mesiodistal), the mean error was
0.57 ± 0.32 mm (range: 0.1–1.1 mm) in the fully
digital group and 0.43 ± 0.26 mm (range: 0.1–
0.9 mm) in the control group (P = 0.249). In the
vertical plane (apico-coronal), the mean error
was 0.67 ± 0.51 mm (range: 0.0–1.6 mm) in the
fully digital group and 0.43 ± 0.32 mm (range:
0.0–1.2 mm) in the control group (P = 0.180).
Discussion
This randomized controlled trial was conducted
with the aim of understanding which procedure
is preferable, a conventional impression and a scan
model or a digital impression, to rehabilitate partially edentulous patients using computer-assisted
template-based implant placement. Implants
were placed flapless or with a minimally invasive
flap and when possible loaded immediately. Both
techniques achieved successful results, and no
statistically significant differences were observed
regarding early implant failure, template-related
complications or virtual planning accuracy.
To the best of our knowledge, at the time of
writing this article, there were no other published
randomized clinical trials comparing conventional
impressions and scan models to digital impressions to plan and rehabilitate partially edentulous
patients using computer-assisted template-based
implant placement. This made it difficult to
evaluate the results of the present study against
comparable studies.
The scientific evidence available concluded
that, regarding implant survival rate, guided surgery has no obvious differences compared with
the conventional protocols.4 However, according
to D’haese et al., the most frequent surgical and
mechanical complications are recognized to be
specifically associated with computer-guided
template-assisted surgery, including misfit of the
surgical guide, fracture of the complete acrylic
denture and misfit of the suprastructure.14 In the
present study, no implant failed early and no
templated-related complications were observed
in either group.
Several independent uncontrolled prospective
studies reported substantial deviations in 3-D
directions between virtual planning and final
implant position, as well as postsurgical complications.15–17 However, excellent clinical results have
also been reported using this technique.13, 14, 18–19
Vasak et al. found a mean deviation of 0.43 mm
(buccolingual), 0.46 mm (mesiodistal) and
0.53 mm (depth) at the level of the implant
shoulder and of 0.70 mm (buccolingual), 0.63 mm
(mesiodistal) and 0.52 mm (depth) at the apex
level, respectively.20 A maximum deviation of
2.02 mm was found in the apico-coronal direction; nevertheless, significantly lower deviations
in the mesiodistal direction were observed for
implants in the anterior region and mandibular
implants than for implants in the posterior
region and maxillary implants. In a historical
systematic review and meta-analysis by Jung
et al., a mean error in angulation of 4.0°, with a
maximum of 20.4°, was found.21 In the present
study, a total mean error of 2.34 ± 1.44° (range:
0.3–5.8°) in angle, 0.49 ± 0.29 mm (range:
0.1–1.1 mm) in the horizontal plane (mesiodistal)
and 0.53 ± 0.42 mm (range: 0.0–1.6 mm) in the
vertical plane (apico-coronal) was found. In all
of the cases, the maximum values (5.8° in angle,
1.1 mm in the horizontal plane and 1.6 mm in the
vertical plane) did not exceed the safe offset of
the software (1.5 mm in the horizontal plane and
2.0 mm in the vertical plane). Although no statistically significant differences were observed
between conventional impressions and scan
models and digital impressions, a trend of higher
discrepancy between virtual and placed implants
was observed in the fully digital group (mean
error of 2.56 ± 1.52° in angle, 0.57 ± 0.32 mm
in the horizontal plane and 0.67 ± 0.51 mm in
the vertical plane). Major deviations were found
for edentulous areas of three or more teeth
(1.1 mm in the horizontal plane in the mandible
and 1.6 mm in the vertical plane in the maxilla).
No data were reported in the scientific literature about the acceptable angle deviation. In the
present study, based on a worse projection using
implants of 3.5 and 4.0 mm in width and 15.0 mm
in length and with standard offset, the maximum
acceptable value ranged from 5.9 to 12.3° (Fig. 10).
In the present study, a higher angular deviation
was found in partially edentulous patients treated
in the control group (5.8°). In contrast, minimum
values of 0.1 mm in the horizontal plane and 0.0
mm in the vertical plane were observed in both
groups, while a minimum angular deviation of 0.3°
was observed in the fully guided group.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 15
[16] =>
Accuracy of computer-assisted implant placement
The main purpose of computer-guided templateassisted surgery is to pre-visualize the approved
prosthetic design of the tooth or teeth to be
replaced and to relate it to the patient’s available
soft and hard tissue. According to a recent study
by Vermeulen, in cases of one or more missing
teeth in the anterior maxilla, guided surgery
yields significantly higher predictability and
accuracy than freehand surgery in transferring
the virtual implant position to a model situation.3
Therefore, implant position can be optimized
according to the esthetic and functional needs
and an interim prosthesis can be manufactured
prior to the surgical procedure, allowing immediate function.
Conclusion
Within the limitations of the present randomized
controlled trial, it was found that intraoral digital impressions may be a viable alternative to
conventional impressions and scan models for
the rehabilitation of partially edentulous patients
using computer-guided template-assisted
implant placement. In both groups, the maximum 3-D deviations did not exceed the safe
offset of the software.
Competing interests
The authors declare that they have no competing interests.
References
1.
Canullo L, Tallarico M, Radovanovic S,
Delibasic B, Covani U, Rakic M.
Distinguishing predictive profiles for
patient-based risk assessment and
diagnostics of plaque induced, surgically
and prosthetically triggered periimplantitis.
→ Clin Oral Implants Res.
2016 Oct;27(10):1243–50.
Epub 2015 Nov 20.
6.
Van Steenberghe D, Glauser R, Blomback
U, Andersson M, Schutyser F, Pettersson A,
Wendelhag I. Computed tomographic
scan-derived customized surgical template
and fixed prosthesis for flapless surgery
and immediate loading of implants in fully
edentulous maxillae: a prospective
multicenter study.
→ Clin Implant Dent Relat Res.
2005;7 Suppl 1:111–20.
2.
Furhauser R, Mailath-Pokorny G, Haas R,
Busenlechner D, Watzek G, Pommer B.
Esthetics of flapless single-tooth implants
in the anterior maxilla using guided
surgery: association of three-dimensional
accuracy and pink esthetic score.
→ Clin Implant Dent Relat Res.
2015 Oct;17 Suppl 2:e427–33.
Epub 2014 Oct 27.
7.
Polizzi G, Cantoni T, Pasini E, Tallarico M.
Immediate loading of variable-thread
expanding tapered-body implants placed
into maxillary post-extraction or healed
sites using a guided surgery approach: an
up-to-five-year retrospective analysis.
→ J Oral Science Rehabilitation.
2016 Sep;2(3):50–60.
3.
Vermeulen J. The accuracy of implant
placement by experienced surgeons:
guided vs freehand approach in a
simulated plastic model.
→ Int J Oral Maxillofac Implants.
2017 Mar/Apr;32(3):617–624.
Epub 2016 Oct 14.
4.
Pozzi A, Tallarico M, Marchetti M,
Scarfo B, Esposito M. Computer-guided
versus free-hand placement of
immediately loaded dental implants:
1-year post-loading results of a
multicentre randomised controlled trial.
→ Eur J Oral Implantol.
2014 Autumn;7(3):229–42.
5.
Tahmaseb A, Wismeijer D, Coucke W,
Derksen W. Computer technology
applications in surgical implant dentistry:
a systematic review.
→ Int J Oral Maxillofac Implants.
2014;29 Suppl:25–42.
8.
Meloni SM, Tallarico M, Pisano M, Xhanari
E, Canullo L. Immediate loading of fixed
complete denture prosthesis supported by
4-8 implants placed using guided surgery:
a 5-year prospective study on 66 patients
with 356 implants.
→ Clin Implant Dent Relat Res.
2017 Feb;19(1):195–206.
Epub 2016 Sep 15.
9.
Tallarico M, Meloni SM, Canullo L, Caneva
M, Polizzi G. Five-year results of a
randomized controlled trial comparing
patients rehabilitated with immediately
loaded maxillary cross-arch fixed dental
prosthesis supported by four or six
implants placed using guided surgery.
→ Clin Implant Dent Relat Res.
2016 Oct;18(5):965–72. Epub 2015 Oct 7.
10.
Chochlidakis KM, Papaspyridakos P,
Geminiani A, Chen CJ, Feng IJ, Ercoli C.
Digital versus conventional
impressions for fixed prosthodontics:
a systematic review and meta-analysis.
→ J Prosthet Dent.
2016 Aug;116(2):184–190.e12.
Epub 2016 Mar 2.
16 Volume 3 | Issue 3/2017
11.
Ahlholm P, Sipila K, Vallittu P, Jakonen M,
Kotiranta U. Digital versus
conventional impressions in fixed
prosthodontics: a review.
→ J Prosthodont.
2016 Aug 2. doi:10.1111/jopr.12527.
[Epub ahead of print]
16.
Merli M, Bernardelli F, Esposito M.
Computer-guided flapless placement of
immediately loaded dental implants in
the edentulous maxilla: a pilot prospective
case series.
→ Eur J Oral Implantol.
2008 Spring;1(1):61–9.
12.
Tallarico M, Meloni SM. Open-cohort
prospective study on early implant failure
and physiological marginal remodeling
expected using sandblasted and
acid-etched bone level implants featuring
an 11° Morse taper connection within one
year after loading.
→ J Oral Science Rehabilitation.
2017 Mar;3(1):68–79.
17.
Johansson B, Friberg B, Nilson H. Digitally
planned, immediately loaded dental
implants with prefabricated prostheses in
the reconstruction of edentulous maxillae:
a 1-year prospective, multicenter study.
→ Clin Implant Dent Relat Res.
2009 Sep;11(3):194–200. Epub 2008 Sep 9.
13.
Meloni SM, Tallarico M, Pisano M, Xhanari
E, Canullo G. Immediate loading of fixed
complete denture prosthesis supported by
4-8 implants placed using guided surgery:
a 5-year prospective study on 66 patients
with 356 implants.
→ Clin Implant Dent Relat Res.
2017 Feb;19(1):195–206. Epub 2016 Sep 15.
14.
D’haese J, Van De Velde T, Komiyama A,
Hultin M, De Bruyn H. Accuracy and
complications using computer-designed
stereolithographic surgical guides for oral
rehabilitation by means of dental implants:
a review of the literature.
→ Clin Implant Dent Relat Res.
2012 Jun;14(3):321–35. Epub 2010 May 11.
15.
Komiyama A, Klinge B, Hultin M.
Treatment outcome of immediately loaded
implants installed in edentulous jaws
following computer-assisted virtual
treatment planning and flapless surgery.
→ Clin Oral Implants Res.
2008 Jul;19(7):677–85.
Journal of
Oral Science & Rehabilitation
18.
Polizzi G, Cantoni T, Pasini E, Tallarico M.
Immediate loading of variable-thread
expanding tapered-body implants placed
into maxillary post-extraction or healed
sites using a guided surgery approach: an
up-to-5-year retrospective analysis.
→ J Oral Science Rehabilitation.
2016 Sep;2(3):50–60.
19.
Tallarico M, Canullo L, Pisano M,
Penarrocha-Oltra D, Penarrocha-Oltra M,
Meloni, SM. An up to 7-year retrospective
analysis of biologic and technical
complication with the All-on-4 concept.
→ J Oral Implantol.
2016 Jun;42(3):265–71. Epub 2015 Dec 11.
20.
Vasak C, Watzak G, Gahleitner A, Strbac G,
Schemper M, Zechner W. Computed
tomography-based evaluation of template
(NobelGuide™)-guided implant positions:
a prospective radiological study.
→ Clin Oral Implants Res.
2011 Oct;22(10):1157–63. Epub 2011 Jan 18.
21.
Jung RE, Schneider D, Ganeles J,
Wismeijer D, Zwahlen M, Hämmerle CH,
Tahmaseb A. Computer technology
applications in surgical implant dentistry:
a systematic review.
→ Int J Oral Maxillofac Implants.
2009;24 Suppl:92–109.
[17] =>
[18] =>
No apicectomy in endodontic surgery
Zero apicectomy in
endodontic microsurgery
Abstract
Background
Randa Harik,a Grace Issaa & Philippe Sleimana, b
a
b
Faculty of Dentistry, Lebanese University, Beirut, Lebanon
Department of Endodontics, Faculty of Dentistry,
Lebanese University, Beirut, Lebanon; Adj Asst Prof.
School of Dentistry, Department of Endodontics,
University of North Carolina at Chapel Hill, Chapel Hill,
N.C., U.S.
Corresponding author:
Prof. Philippe Sleiman
Dekwaneh SLAF St.
5th floor Mimosa bldg.
Beirut
Lebanon
T + 96 114 94 779
profsleiman@gmail.com
Surgical endodontic treatment is an option for teeth with periapical periodontitis and may be indicated for teeth previously submitted to unsuccessful endodontic treatment and teeth with a strong possibility of failure by
the nonsurgical approach. This procedure includes root sectioning and
preparation of a cavity in the root canal followed by retrograde obturation.
Furthermore, the presence of apical true cysts requires surgical treatment as well, as these cysts are less likely to heal by nonsurgical root
canal therapy because they are self-sustaining and no longer dependent
on the presence or absence of root canal infection. Accordingly, surgical
intervention of apical true cysts is necessary.
The limitations of periapical radiography have led to significant interest in cone beam computed tomography (CBCT) in endodontic applications. The number of CBCT scans taken every year is increasing as awareness increases, resolution increases and costs decrease.
Case presentation
How to cite this article:
Harik R, Issa G, Sleiman P. Zero apicectomy
in endodontic microsurgery.
J Oral Science Rehabilitation.
2017 Sep;3(3):18–26.
In this article, we describe a new approach in surgical endodontics that
focuses on preserving the integrity of the apical part of the root. This
approach entails conducting root canal treatment and surgical cyst
removal in one session. We illustrate this approach with a series of cases
showing the preoperative condition and postoperative healing, with a
recall period of 6 months, 1 year, 2 years, and yearly up to 5 years.
Conclusion
Zero apicectomy in endodontic surgery is a novel technique that combines
high-resolution CBCT visualization of the apical situation, root canal
treatment with the use of efficient irrigation with EndoVac, and root
surface conditioning in order to allow the preservation of the apical part
of the root ad integrum. Zero apicectomy clears the infection from inside
the bone and treats the root canal in the same session, giving the body a
greater opportunity to heal in a healthy, clean environment. Current literature has not described this technique; however, clinical cases have
proven its success.
Keywords
Apicectomy, EndoVac, CBCT, surgical endodontic treatment.
18 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[19] =>
No apicectomy in endodontic surgery
Introduction
Surgical endodontic treatment is an option for
teeth with apical periodontitis and may be indicated for teeth previously submitted to unsuccessful endodontic treatment and teeth with a
strong possibility of failure by the nonsurgical
approach.6, 14, 29 This procedure usually consists
of several steps, including retrograde obturation,
which is performed after root sectioning and
preparation of a cavity in the root canal.6
Furthermore, the presence of apical true
cysts requires surgical treatment as well, as
these cysts are less likely to heal by conventional
root canal therapy because they are selfsustaining and no longer dependent on the presence or absence of root canal infection.8, 26, 24
Accordingly, surgical intervention of apical true
cysts is necessary.15, 20, 23, 25 This technique can
be performed when conducting a root canal
treatment or a retreatment of the root canal
system, combined with a surgical approach for
the removal of the cyst. If access to the root
canal system is not possible, a conventional apicectomy can be performed.
The limitations of periapical radiography
have led to significant interest in cone beam
computed tomography (CBCT) in endodontic
applications. It seems that number of CBCT
scans taken every year is increasing as awareness increases, resolution increases and costs
decrease.28 With the use of CBCT, cystic lesions
are easily identified.
In this article, we will describe a new
approach in surgical endodontics that focuses
on preserving the integrity of the apical part of
the root. We will illustrate this approach with a
series of cases showing the preoperative condition and postoperative healing.
Materials and methods
Once there is a positive diagnosis of an apical
cyst with CBCT, the patient is informed of the
situation and the different steps of the treatment. The procedure is performed under local
anesthesia with the use of articaine with
1:100,000 epinephrine infiltrated under the periosteum. We then proceed by isolating the tooth
or teeth with a rubber dam and then shaping and
cleaning the root canal system. The irrigation is
conducted with the EndoVac negative-pressure
device (SybronEndo, Orange, Ca., U.S.).21 Once
the working length has been determined elec-
tronically, the irrigation cannula can be placed
at the working length.21 After the irrigation is
completed, a temporary filling is placed in the
access cavity and the rubber dam removed. The
obturation of the canal is deferred, as the canal
cannot be properly dried at this stage.
The following step is performing the surgical
part, first by raising a flap and identifying the
cyst. The cystic area is carefully spooned out
while preserving the cementum and ligaments
that are attached to the root surface. The
exposed part of the root is rinsed with normal
saline followed by the application of citric acid
at a neutral pH with a microbrush on the root
surface. After the latter step, the area is rinsed
abundantly again with sterile water or normal
saline. As the flap is temporarily put back in
place, the tooth or teeth are isolated again with
a rubber dam, the temporary filling is removed
and a full sequence of irrigation with the use of
EndoVac is conducted again. The master cone is
adjusted, and full obturation of the root canal
system is performed using warm vertical obturation. A temporary filling material is then placed
in the access cavity and the isolating dam
removed. The final step consists of raising the
flap again and checking whether any large extrusion of the obturation material occurred that
would need to be removed. The sutures are
placed, and postoperative medication is prescribed.
Discussion
Apical periodontitis (AP) is an inflammatory or
immune response in the apical periodontium
that often results from intracanal microorganisms. The resulting apical bone resorption is a
defense mechanism that prevents the spread of
infection and appears radiolucent on radiographs.23, 16 Because AP is usually asymptomatic,
it is frequently only detected during routine
radiographic examination.4 In this sense, radiography is essential for the successful and
timely diagnosis of AP and historically has been
limited to periapical and panoramic radiographs.1
Furthermore, radiographic imaging is essential
in all stages of endodontics, from diagnosis
through long-term assessment of healing outcomes. In conjunction with symptoms, outcome
is assessed by comparison of preoperative and
immediate postoperative radiographs, with subsequent radiographs taken at recall appointments.12, 18
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 19
[20] =>
No apicectomy in endodontic surgery
The diagnostic value of pretreatment radiographs depends on how well they reflect the
histology of AP. Studies that have investigated
the correlation between histological appearance
and radiographic manifestations have found that
the absence of radiographic signs does not preclude apical inflammation, and the radiographic
appearance is always smaller than the histological extent of the lesion.20–23 Radiographic signs
pathognomonic of AP include radiolucent
changes in periradicular trabecular pattern and
altered shape and width of the periodontal ligament (PDL) space.3, 7, 11, 13 However, periapical
radiographs and panoramic imaging have inherent limitations, such as superimposition and
distortion of important structures that commonly mask lesions.17, 19 In addition, lesions in
cancellous bone cannot be consistently detected
with these radiographic techniques.5 Therefore,
in some cases, extensive bone resorption may
be present even when there is no radiographic
evidence of it.5 The appearance of the periapical
tissue on a radiograph is influenced by the superimposition of anatomical structures and the
variable nature of the overlying bone density and
texture.12, 18 The limitations of periapical radiography have led to significant interest in CBCT.
Currently, the use of CBCT imaging has made
it possible to visualize the related anatomical
structures in 3-D with higher resolution. This
has improved the overall diagnostic efficacy and
made early diagnosis possible for some specific
clinical situations. 22, 27 In endodontic practice,
CBCT imaging with limited fields of view has
been suggested for diagnosis in patients with
contradictory or nonspecific clinical signs and
symptoms.27
Postsurgical excisional wound healing after
periradicular surgery entails dentoalveolar healing (i.e., reestablishment of an apical attachment
apparatus) and alveolar healing (i.e., osseous
repair of trabecular and cortical bone).2 Cementum deposition on the root end is considered the
critical step in dentoalveolar wound healing.2
Consequently, creating an environment conducive to cementogenesis should enhance the healing process after surgical endodontic treatment.
In periodontal surgery, dentin demineralization leads to enhanced connective tissue attachment through splicing of exposed dentinal collagen with new collagen fibers produced during
wound healing and early deposition of cementum on the dentinal surfaces.9
Demineralizing the root surface with citric
acid has been shown to increase cementogenesis
20 Volume 3 | Issue 3/2017
and promote periradicular wound healing by
exposing the collagen matrix, which stimulates
fibroblast attachment and growth.9 The lower
pH of citric acid may induce initially a more
intense inflammatory response compared with
saline. This may inhibit the healing process as
measured by new bone formation. As healing
progresses, the potential benefits of the anticollagenase activity may allow for more rapid
collagen formation and ultimately allow more
rapid new bone formation.10
The irrigation is conducted with EndoVac, as
the EndoVac System safely delivers irrigants to
the apical terminus of root canals.21 The device
consists of a delivery/evacuation tip attached to
a syringe of irrigant and the high-volume suction
of the dental chair. Using a combination of a
macro- or microcannula attached to the suction
device, the irrigant introduced into the pulp
chamber is pulled by negative pressure down
the canal into the tip of the cannula and removed
through the suction hose, thus avoiding any
extrusion of the irrigant outside the root canal
area, since the PDL barrier is lost then and the
use of conventional irrigating methods could
result in pushing the chemicals into the exposed
surgical site.21
Case descriptions
Case 1
The patient was referred to the clinic with a
swelling in the palatal area of the maxillary lateral incisor (Figs. 1a & b). Axial slices of CBCT
cans showed substantial bone loss at the apical
level of the maxillary lateral incisor (Fig. 1c) and
at the level of the two maxillary central incisors
(Fig. 1d).
After administration of the anesthesia, a
syringe was inserted into the palatal mucosa
and a large amount of pus was aspirated. After
following the procedural steps previously
described and the removal of the cystic reaction,
a long section of the root canals was exposed,
especially that of the lateral and central incisors.
Immediate postoperative radiographs were
taken (Figs. 1e & f), and then 1-year follow-up
radiographs (Figs. 1g & h). The 1-year follow-up
images showed the formation of new bone
around the teeth and of a new PDL. The 5-year
follow-up radiograph (Fig. 1i) indicated an intact
PDL, a smaller fibrous area and no signs of external or internal resorption.
Journal of
Oral Science & Rehabilitation
[21] =>
No apicectomy in endodontic surgery
Figs. 1a & b
Fig. 1c
Figs. 1a & b
Preoperative periapical and
panoramic radiographs.
Fig. 1c
CBCT axial slices.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 21
[22] =>
No apicectomy in endodontic surgery
Fig. 1d
Fig. 1e
Figs. 1f–i
1 year
Fig. 1d
CBCT 3-D reconstruction
demonstrating the extent of
the lesion(s).
Figs. 1e & f
Immediate postoperative
radiographs of the lateral incisor
(left) and central incisor (right).
Figs. 1g & h
One-year follow-up
radiographs.
Fig. 1i
Five-year follow-up
radiograph.
Case 2
The patient was referred to have a mandibular
molar checked. He was trying by all means to
retain the molar, even though he had been
advised to have it extracted and replaced with
an implant. The preoperative radiograph (Fig. 2a)
showed a substantial periapical lesion, although
the previous dentist had placed calcium hydroxide paste in the canals. Furthermore, the patient
was complaining of tingling in his lower lip. The
i-CAT (KaVo Dental, Biberach, Germany) showed
22 Volume 3 | Issue 3/2017
5 years
that the cystic reaction extended far, almost
reaching the mandibular canal (Fig. 2b).
The same approach as described previously
was performed in an attempt to treat and save
the molar. Once the flap had been elevated, it
appeared that the cystic reaction was also manifesting under the periosteum above the cortical
bone and there was another cystic reaction close
to the mandibular nerve (Fig. 2c). Postoperative
radiographs were taken (Fig. 2d) and complete
healing was seen with full reconstruction of the
bone (Fig. 2e).
Journal of
Oral Science & Rehabilitation
[23] =>
No apicectomy in endodontic surgery
Fig. 2a
Preoperative periapical
radiograph.
Fig. 2a
Fig. 2b
CBCT images of the patient.
Fig. 2c
The cystic reaction in the
vicinity of the mandibular
canal.
Fig. 2d
Immediate postoperative
radiograph (left).
Fig. 2b
Fig. 2e
One-year follow-up
radiograph.
Fig. 2f
Two-year follow-up
radiograph.
Fig. 2c
Fig. 2d
Figs. 2e & f
1 year
Journal of
Oral Science & Rehabilitation
2 years
Volume 3 | Issue 3/2017 23
[24] =>
No apicectomy in endodontic surgery
Figs. 3a–c
Fig. 3d
Figs. 3a–c
Preoperative radiographs:
maxillary anterior teeth.
Figs. 3d & e
CBCT images.
Case 3
The patient was referred to the clinic to have the
maxillary anterior teeth checked. The patient had
had crowns placed several years before and apparently the pulps of those teeth had become necrotic
and resulted in periapical infections. On the preoperative radiographs (Figs. 3a–c) and on the i-Cat
(Figs. 3d & e), the periapical cysts could be easily
identified and massive bone loss was evident.
24 Volume 3 | Issue 3/2017
The same approach as described previously was
used to treat all of the anterior teeth to remove
the multiple cysts while preserving the bone as
far as possible and only using the bone defect
that was created by the infection to scoop out
the cystic reaction (Figs. 3f & g). Postoperative
radiographs were taken (Fig. 3h), as well as
radiographs at the 18-month follow-up (Fig. 3i).
Further follow-up was not done, as the patient
was unavailable.
Journal of
Oral Science & Rehabilitation
[25] =>
No apicectomy in endodontic surgery
Fig. 3e
Figs. 3f & g
Figs. 3f & g
Intraoperative photographs
showing the defects resulting
from the cystic reactions.
Fig. 3h
Immediate postoperative
radiographs.
Fig. 3i
Eighteen-month
follow-up radiographs.
Figs. 3h & i
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 25
[26] =>
No apicectomy in endodontic surgery
Conclusion
techniques, in which we drain the cyst for a
certain period without having the ability to
know in advance if surgery will be needed
later, zero apicectomy clears the infection
from inside the bone and treats the root canal
in the same session, giving the body a greater
opportunity to heal in a healthy, clean environment. Current literature has not described
this technique; however, clinical cases have
proven its success.
Zero apicectomy in endodontic surgery is a
novel technique that combines high-resolution
CBCT visualization of the apical situation with
the use of efficient irrigation with EndoVac,
root canal treatment and root surface conditioning in order to allow the preservation of
the apical part of the root ad integrum. Preserving the total length of the root has many
benefits, including, most importantly, the stability and longevity of the tooth, as cutting the
Competing interests
root exposes dentinal tubules. Since we perform retrograde obturation of the main canal,
we cannot guarantee that the exposed dentin The authors declare that they have no competis bacteria-free. Comparing this with other ing interests.
References
1.
American Association of Endodontists and
American Academy of Oral and
Maxillofacial Radiology. Use of cone-beam
computed tomography in endodontics.
Joint position statement of the American
Association of Endodontists and the
American Academy of Oral and
Maxillofacial Radiology.
→ Oral Surg Oral Med Oral Pathol Oral
Radiol Endod.
2011 Feb;111(2):234–7.
8.
Cohn S, Hagreaves K. Pathways of the
pulp. 9th ed.
→ St Louis: Mosby.
2006. 662 p.
2.
Andreasen JO. Cementum repair after
apicoectomy in humans.
→ Acta Odontol Scand.
1973 Oct;31(4):211–21.
10.
Davis JL, Jeansonne BG, Davenport WD,
Gardiner D. The effect of irrigation with
doxycycline or citric acid on leakage and
osseous wound healing.
→ J Endod.
2003 Jan;29(1):31–5.
3.
Barthel CR, Zimmer S, Trope M.
Relationship of radiologic and histologic
signs of inflammation in human root-filled
teeth.
→ J Endod.
2004 Feb;30(2):75–9.
4.
Bender IB. Factors influencing the
radiographic appearance of bony lesions.
→ J Endod.
1982 Apr;8(4):161–70.
9.
Craig KR, Harrison JW. Wound healing
following demineralization of resected root
ends in periradicular surgery.
→ J Endod.
1993 Jul;19(7):339–47.
11.
Fouad AF, Walton RE, Rittman BR. Induced
periapical lesions in ferret canines:
histologic and radiographic evaluation.
→ Endod Dent Traumatol.
1992 Apr;8(2):56–62.
12.
Gelfand M, Sunderman EJ, Goldman M.
Reliability of radiographical interpretations.
→ J Endod.
1983 Feb;9(2):71–5.
5.
Bender IB, Seltzer S. Roentgenographic
and direct observation of experimental
lesions in bone: II.
→ J Am Dent Assoc.
1961 Jun;62(6):708–16.
6.
Bernarde RA, De Moraes IG, Garcia RB,
Bernardineli N, Baldi JV, Victorino FR,
Vasconcelos BC, Duarte MA, Bramante
CM. Evaluation of apical cavity preparation
with a new type of ultrasonic diamond tip.
→ J Endod.
2007 Apr;33(4):484–7.
7.
Brynolf, I. A histological and roentgenological study of the periapical region of human
upper incisors.
→ Odontologisk Revy.
1967. Almquist & Wiksell;18: 1-176.
13.
Green TL, Walton RE, Taylor JK, Merrell P.
Radiographic and histologic periapical
findings of root canal treated teeth in
cadaver.
→ Oral Surg Oral Med Oral Pathol Oral
Radiol Endod.
1997 Jun;83(6):707–11.
14.
Gutmann JL, Harrison JW, editors. Surgical
endodontics: past, present, and future. In:
Surgical endodontics.
→ Cambridge: Blackwell Scientific.
1991. p. 216–30.
15.
Ingle J, Bakland L, Baugartner C. Ingle’s
endodontics. 6th ed.
→ St Louis: Saunders.
2009. 221–308 p.
26 Volume 3 | Issue 3/2017
16.
Kakehashi S, Stanley HR, Fitzgerald RJ.
The effects of surgical exposures of dental
pulps in germ-free and conventional
laboratory rats.
→ Oral Surg Oral Med Oral Pathol.
1965 Sep;20:340–9.
17.
Katebzadeh N, Hupp J, Trope M.
Histological periapical repair after
obturation of infected root canals in dogs.
→ J Endod.
1999 May;25(5):364–8.
18.
Lambrianidis T. Observer variations in
radiographic evaluation of endodontic
therapy.
→ Endod Dent Traumatol.
1985 Dec;1(6):235–41.
19.
LeQuire AK, Cunningham CJ, Pelleu GB Jr.
Radiographic interpretation of experimentally produced osseous lesions of the
human mandible.
→ J Endod.
1977 Jul;3(7):274–6.
20.
Lin LM, Ricucci D, Lin J, Rosenberg PA.
Nonsurgical root canal therapy of large
cyst-like inflammatory periapical lesions
and inflammatory apical cysts.
→ J Endod.
2009 May;35(5):607–15.
21.
Miller TA, Baumgartner JC. Comparison of
the antimicrobial efficacy of irrigation
using the EndoVac to endodontic needle
delivery.
→ J Endod.
2010 Mar;36(3):509–11.
22.
Nair MK, Nair UP. Digital and advanced
imaging in endodontics: a review.
→ J Endod.
2007 Jan;33(1):1–6.
Journal of
Oral Science & Rehabilitation
23.
Nair PN. New perspectives on radicular
cysts: do they heal?
→ Int Endod J.
1998 May;31(3):155–60.
24.
Nair PN, Sjogren U, Schumacher E,
Sundqvist G. Radicular cyst affecting a
root-filled human tooth: a long-term
post-treatment follow-up.
→ Int Endod J.
1993 Jul;26(4):225–33.
25.
Natkin E, Oswald RJ, Carnes LI. The
relationship of lesion size to diagnosis,
incidence, and treatment of periapical
cysts and granulomas.
→ Oral Surg Oral Med Oral Pathol.
1984 Jan;57(1):82–94.
26.
Orstavik D, Pitt Ford TR. Essential
endodontology. 2nd ed.
→ Oxford: Blackwell Science.
2008. 488 p.
27.
Patel S, Durack C, Abella F, Shemesh H,
Roig M, Lemberg K. Cone beam computed
tomography in endodontics—a review.
→ Int Endod J.
2015 Jan;48(1):3–15.
28.
Pope O, Sathorn C, Parashos PA.
Comparative investigation of cone-beam
computed tomography and periapical
radiography in the diagnosis of a healthy
periapex.
→ J Endod.
2014 Mar;40(3):360–5.
29.
Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z.
Retrospective evaluation of surgical
endodontic treatment: traditional versus
modern technique.
→ J Endod.
2006 May;32(5):412–6.
[27] =>
The Dental Tribune
International Magazines
www.dental-tribune.com
I would like to subscribe to
EUR 44 per year (4 issues per year; incl. shipping and VAT for customers in Germany) and EUR 46
per year (4 issues per year; incl. shipping for customers outside Germany).
CAD/CAM
ortho**
Clinical Masters*
prevention*
cosmetic dentistry*
roots
implants
Journal of Oral Science
** EUR 22 per year (2 issues per year; incl. shipping and VAT for customers in Germany) and EUR 23
per year (2 issues per year; incl. shipping for customers outside Germany).
laser
& Rehabilitation***
*** EUR 200 per year (4 issues per year; incl. shipping and VAT).
* EUR 12 per year (1 issue per year; incl. shipping and VAT for customers in Germany) and EUR 14
per year (1 issue per year; incl. shipping for customers outside Germany).
Your subscription will be renewed automatically every year until a written cancellation is sent
to Dental Tribune International GmbH, Holbeinstr. 29, 04229 Leipzig, Germany, six weeks prior
to the renewal date.
Shipping Address
Name
Address
Zip Code, City
Country
E-mail
Date, Signature
PayPal
Credit Card
Credit Card Number
SUBSCRIBE NOW!
F +49 341 48474 173
subscriptions@dental-tribune.com
Expiration Date
Security Code
[28] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
How can the tapered implant
design influence bundle
bone preservation: An experimental study in American
Foxhound dogs
Abstract
José Luis Calvo Guirado,a José Eduardo Maté Sánchez
de Val,a María Piedad Ramírez Fernández,a Carlos Pérez
Albacete Martínez,a Rafael Arcesio Delgado Ruíz,b
Sérgio Alexandre Gehrke,a, c José Antonio Benítez Garcíaa
& Manuel Fernández Domínguezd
a
International Dentistry Research Cathedra, Faculty
of Health Sciences, Universidad Católica San Antonio
de Murcia, Murcia, Spain
b
Department of Prosthodontics and Digital Technology,
School of Dental Medicine. Stony Brook University,
Stony Brook, N.Y., U.S.
c
Catholic University of Uruguay, Montevideo, Uruguay
d
School of Medicine,Department of Dentistry.
CEU San Pablo University, Madrid, Spain
Corresponding author:
Prof. José Luis Calvo Guirado
Faculty of Health Sciences
Universidad Católica San Antonio de Murcia
Campus de los Jerónimos
Nº 135 Guadalupe
30107 Murcia
Spain
jlcalvo@ucam.edu
How to cite this article:
Calvo Guirado JL, Maté Sánchez de Val JE,
Ramírez Fernández MP, Pérez Albacete Martínez C,
Delgado Ruíz RA, Gehrke SA, Benítez García JA.
Fernández Domínguez M, How can the tapered implant
design influence bundle bone preservation:
An experimental study in American Foxhound dogs.
J Oral Science Rehabilitation.
2017 Sep;3(3):28–36.
Objective
The objective of the present study was to evaluate bone–implant contact
(BIC) in a new implant design after immediate and delayed placement at
different levels in relation to crestal bone in American Foxhound dogs.
Materials and methods
The second, third and fourth mandibular premolars and first molars of
6 American Foxhound dogs were extracted bilaterally. At random, 4
immediate implants were placed in the hemimandibles of each dog in the
crestal (control group) and subcrestal position (test group). Three dogs
were allowed a healing period of 8 weeks; the other 3 had a healing period
of 12 weeks. After the healing periods, histomorphometric analysis of
the specimens was performed to measure BIC values and bone remodeling in crestal and subcrestal implants.
Results
All of the implants healed without incident and were available for histological analysis. Lower bone resorption was observed in the group of
implants placed subcrestally in healed bone and immediately postextraction.
Conclusion
Our findings suggest that less resorption can be expected when implants
are inserted 2 mm subcrestally overall for both immediate and deferred
implants compared with placement at the crestal level. In addition, higher
BIC values were found at 12 weeks of follow-up in the group of implants
placed subcrestally in healed bone compared with those placed subcrestally immediately.
Keywords
Top DM, tapered implants, healed bone.
28 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[29] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
Introduction
After loss of a tooth, there is progressive involution of the alveolar bone in both the horizontal
and vertical dimensions.4, 5, 17, 18 In addition, the
most rapid reduction of alveolar bone after
dental extraction occurs during the first
months.4, 5
For more than a decade, different clinical
studies have demonstrated that immediate
implant placement in fresh extraction sites may
be an effective therapy not only because it
reduces the number of surgical procedures,37, 41
but also because it favors the preservation of
the ridges’ morphological contours and simplifies clinical techniques. 11, 28, 35, 50, 51 Bone remodeling begins directly after the preparation of the
implant bed, as well as the healing process of
the bone. Osteoblast adhesion to the implant
surface and the osseointegration process begins
approximately 3 weeks after surgery.54 During
this healing process, bone remodeling occurs.33, 49
This often results in crestal bone loss.31, 32 However, findings from experiments in humans and
dogs have demonstrated that marked reduction
in the height of the alveolar ridge occurred consistently after tooth extraction4 and that implant
placement in fresh extraction sockets had no
effect on the process of bone modeling. 5, 9, 17, 18
Several authors have studied the clinical and
radiographic changes that occur around dental
implants inserted at different levels in relation
to the crestal bone. Clinically, implants are often
placed subcrestally in esthetic areas to avoid
exposure to metals and to create sufficient space
to develop a suitable emergence profile.21 Subcrestal placement of implants may have an additional benefit, as it improves bone–implant contact (BIC) in the neck region of the implant.30, 59
Positioning the implant–abutment junction
more apically contributes to the maintenance of
mucosal texture and tonality and favors the
re-establishment of marginal tissue architecture.27 Thus, different microgap designs result
in different shapes and sizes of the periimplant
(dis-shaped) bone defect in submerged implants
in either equicrestal or subcrestal positions.58 A
previous animal study evaluated bone remodeling and BIC after immediate placement at different levels in relation to the crestal bone of
beagle dogs. Cylindrical and tapered implants
were inserted crestally and 2 mm subcrestally.
These studies suggested that apical positioning
of the top of the implant does not jeopardize
bone crest and periimplant tissue remodeling.
However, less resorption was observed when
implants were placed 2 mm subcrestally. Moreover, higher BIC values were found in implants
placed subcrestally.38, 39
Bone–implant contact is among the most
important factors contributing to implant stability. Thus, many authors have specified the
factors that influence BIC levels, implant position and bone density.23, 24, 26, 46, 56, 57 Experimental and clinical studies have demonstrated that
implants designed with a shorter, smooth coronal collar caused no additional bone loss and
might help reduce the risk of an exposed metal
implant margin in areas of esthetic concern.3, 29
The anatomy and surface treatment of the
neck of the implant, together with the type of
connection between the implant and the prosthetic components, have been considered as
with regard to reducing crestal bone loss. 27
Based on the data revised, it is hypothesized that
the vertical positioning of the implant platform
in relation to the crestal bone may influence the
location of the first BIC. As a consequence, the
biological width may be established in a more
coronal position. Therefore, the objective of this
study was to compare the BIC of implants with
smooth necks and no microthreads, which represent a rough surface, placed at crestal and
subcrestal levels in healed bone and immediately
post-extraction in dogs.
Materials and methods
Six American Foxhound dogs of approximately
1 year of age were used in this study. The Ethics
Committee for Animal Research at the University of Murcia, Murcia, Spain, approved the study
protocol, which followed guidelines established
by the European Union Council Directive of February 2013 (R.D.53/2013). Clinical examination
determined that all of the animals were in good
general health; moreover, all of the animals presented with intact maxillae, without any general
occlusal trauma or oral viral or fungal lesions.
The choice of this kind of dog was due to
these being the animals that we have in our
animal facilities approved for research. The animals were quarantined for the application of
rabies vaccines and vitamins. The dogs were
kept in kennel cages before and after surgery,
received appropriate veterinary care, and were
allowed free access to water and standard laboratory nutritional support throughout the trial
period. After surgery, the animals received
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 29
[30] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
antibiotics (enrofloxacin, 5 mg/kg, bid) and anal- implants, the healing abutments were congesics (meloxicam, 0.2 mg/kg, tid) via the sys- nected to evaluate the periimplant soft tissue.
temic route.
The flaps were sutured with 4-0 silk (Lorca
Marín, Lorca, Spain).
Surgical procedure
After the surgical procedures, the animals
received antibiotic treatment (amoxicillin,
The animals were pre-anesthetized with ace- 500 mg, bid) and analgesics (ibuprofen, 600 mg,
promazine (0.12%, 0.25 mg/kg), buprenorphine tid) systemically. In addition, the dogs were fed
(0.01 mg/kg) and medetomidine (35 μg/kg). The a soft diet for 7 days and plaque control was
mixture was injected intramuscularly into the maintained through the application of Sea4
femoral quadriceps. The animals were then (Blue Sea Laboratories, Alicante, Spain). The
taken to the operating theater, where, at the wounds were inspected daily for postoperative
earliest opportunity, an intravenous catheter clinical complications. Two weeks after surgery,
was inserted (diameter of 22 or 20 G) into the the sutures were removed.
cephalic vein, and propofol was infused at a slow,
Histological and
constant infusion rate of 0.4 mg/kg/min. Conhistomorphometric analysis
ventional dental infiltration anesthesia (articaine, 40 mg; 1% epinephrine) was administered
at the surgical sites. These procedures were Three animals were sacrificed at 8 weeks and
carried out under the supervision of a veterinary the other 3 animals were sacrificed at 12 weeks
surgeon. Mandibular premolar and molar through an overdose of Pentothal Natrium (Labextractions (P2, P3 , P4 and M1) were performed oratorios Abbot, Madrid, Spain) and perfused
bilaterally. The teeth were sectioned in the buc- through the carotid arteries with a fixative concolingual direction at the bifurcation using a taining 5% glutaraldehyde and 5% formaldetungsten carbide bur so that the roots could be hyde. The specimens were washed in saline and
extracted individually without damaging the fixed in 10% buffered formalin. The specimens
remaining bony walls with a contra-angle hand- were processed to obtain thin sections of soil
piece (W&H, Bürmoos, Austria). The surgical with the Precise 1 automated system (Assing,
device used for odontosection was the Rome, Italy). The specimens were dehydrated in
ascending series with alcohol and embedded in
Implantmed (W&H).
Crestal incisions were performed bilaterally a glycol methacrylate resin (Technovit 7200
in the premolar–molar region of the mandible. VLC, Kulzer, Wehrheim, Germany). After polymFull-thickness mucoperiosteal flaps were ele- erization, the specimens were sectioned along
vated, and recipient sites in the molar regions their longitudinal axes with a high-precision
on both sides of the mandible were prepared for diamond disk, at about 150–30 μm. A total of
the present experiment, while the other regions 2 slides were obtained for each implant. The
were used for different experimental purposes, slides were stained with toluidine blue and
the results of which are reported elsewhere. The observed under a normal transmitted light
healed bone was prepared to place cylindrical, microscope and a polarized light microscope
self-tapping implants with BIONER’s Top DM (Leitz, Wetzlar, Germany).
The histological preparation evaluated the
expansive core (BIONER Sistemas Implantológicos, Sant Just Desvern, Spain; 8.0 mm in length, distance from the top of the implant collar to the
3.5 mm in diameter). A total of 48 implants were first contact with buccal and lingual bone (A-Bc
installed, 8 in each dog in healed and post- and A-Lc), as well as the heights of the buccal
extraction bone (Figs. 1a–d). The implants had and lingual bone ridges with respect to the neck
a bioetch surface characterized by a moderate, of the implant (Fig. 2). Resorption of the buccal
acid-etched without sandblasting, roughness bone wall compared with resorption of the lingual bone wall was expressed as a linear meaalong the implant body.
The crestal or subcrestal positioning of the sure. The buccal and lingual bone plates were
implants and the type of placement (healed bone measured from the implant shoulder to the first
or immediately post-extraction) were deter- BIC and to the top of the bony crest. The permined randomly by the randomization plan gen- centage of BIC of native bone was also measured
erator at www.randomization.com. The sub along the perimeter of the implant between the
crestal position was 2 mm below the buccal and coronal end of osseointegration at the buccal
lingual bone crests. After insertion of the and lingual aspects. The apical portion of each
30 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[31] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
Figs. 1a & b
Figs. 1a–d
(a) Healed bone.
(b) Separate flap where
bone repair was observed
after 8 weeks of healing.
(c) Top DM implant.
(d) Implants with healing
screws placed at crestal
and subcrestal levels.
a
b
c
d
implant was excluded from the measurement
because some implants were inserted into the
dental nerve. The total amount of bone in contact with the implant was calculated as the sum
of native bone and newly formed bone (BIC%).
Histomorphometry of BIC percentages was performed using a light microscope (Laborlux S,
Leitz) connected to a high-resolution video
camera (3CCD, JVC KY-F55B, Yokohama, Japan)
and connected to a monitor and PC (Intel
Pentium III 1200 MMX, Intel, Santa Clara, Calif.,
U.S.). This optical system was associated with
a scanning pad (Matrix Vision, Oppenweiler, Germany) and a software package for histometry
with image capture capabilities (Image-Pro Plus
4.5, Media Cybernetics, Immagini & Computer,
Milan, Italy). The total amount of bone in contact
with the implants was calculated as the sum of
native bone and newly formed bone.
Figs. 1c & d
Fig. 2
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 31
Fig. 2
The histological preparation
evaluated the distance from
the top of the implant collar to
the first contact with buccal
and lingual bone (A-Bc and
A-Lc), as well as the heights of
the buccal and lingual bone
ridges with respect to the neck
of the implant.
[32] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
Statistical analysis
Mean values and standard deviations were calculated using a BIC descriptive test and bone
resorption measurements. The Wilcoxon test
was applied to the comparison of mean averages
and to quantify relationships between differences. Brunner and Langer nonparametric tests
were applied to the mean values for crestal and
subcrestal implants and for periimplant mucosa
measurement. All histomorphometric parameters were analyzed using descriptive methods
(IBM SPSS Statistics for Windows version 19.0,
IBM Corp., Armonk, N.Y., U.S.). For all of the tests
performed, the significance level chosen was
5% (p < 0.05).
Results
When buccal, lingual, mesial and distal dimensions of the entrance to the fresh extraction
sockets were measured before implant placement, mean alveolar ridge measurements of the
extraction sockets were 5.3 ± 0.6 mm (2P2),
5.7 ± 0.2 mm (3 P 3), 5.9 ± 0.2 mm (4 P4) and
8.9 ± 0.5 mm (1M1).
Histological evaluation
Healing was uneventful for all of the animals and
no implants were lost. Operative surgical sites
healed without incident. All of the implants were
available for histological analysis. The gaps
between all of the implants and the bony walls
disappeared as a result of bone filling and
resorption of the alveolar crest in both groups
(control and test). Direct contact between the
living bone with slight vestibular resorption was
observed, with stable soft tissue at 8 weeks for
the crestal position and with a thicker gingiva in
implants placed at the subcrestal level. Bone
remodeling in the region of the marginal defect
was accompanied by marked decreases in the
dimensions of the buccal and lingual bone walls
at 12 weeks at crestal and subcrestal levels
(Figs. 3 & 4). For all of the implants, the keratinized oral epithelium was continuous with the
junctional epithelium along the implants and the
healing screws. Underlying connective tissue
was observed with a dense network of collagen
fibers around the implants placed in subcrestal
healed bone, improving the quality of the periimplant gingiva (Fig. 5) compared with crestally
placed implants.
32 Volume 3 | Issue 3/2017
After evaluation of all of the measurements, the
distance from the top of the implant neck to the
first BIC at the buccal aspect (A-Bc) showed
statistically significant differences at 12 weeks
in the test group compared with the control
group (Figs. 6 & 7). In addition, the distance from
the top of the implant collar to the lingual bone
crest (A-Lc) showed significant differences
between the crestal group and the subcrestal
group after the healing period of 8 weeks. The
A-Lc measure (distance between the implant
collar top and the first BIC in the lingual aspect)
was statistically significant after the healing
period of 12 weeks in the subcrestal group.
Total BIC values were higher for implants of
the test group at 8 weeks with subcrestal placement and even higher in this group of implants
after 12 weeks of healing compared with the
crestal placement group (Table 1). The values of
the BIC lingual aspect are described in Table 2.
These were higher for the subcrestal group, and
values increased from 8 to 12 weeks. The direct
contact surface between the implant and the
bone was larger for the test implants, with no
statistically significant differences. Subcrestal
placement always showed higher BIC values at
8 and 12 weeks (Figs. 5 & 8).
Table 3 shows that the analysis of the periimplant mucosa and buccal implant shoulder
(PM-IS BC) presented higher values for the
implants placed crestally at 8 and 12 weeks compared with subcrestal placement, with statistically significantly different values at 12 weeks.
Discussion
The removal of single teeth followed by immediate placement of an implant results in marked
alterations to buccal ridge dimensions (30–43%)
and the horizontal (63–80%) and vertical
(65–69%) gaps between the implant and bone
walls. 46 The present investigation showed
marked alterations after a healing period of
8 weeks that affected both the buccal and lingual
bone walls. A-Bc and A-Lc values were lower for
implants placed in healed bone at the subcrestal
level than for those placed at the crestal level In
addition, resorption was more pronounced, which
is in agreement with studies previously published
by our group.23 The present study revealed a
greater depth of crestal bone resorption in the
buccal bone than in the lingual crest. This bone
dehiscence after implant placement corroborates
the previously reported findings.4, 5, 23, 25, 52
Journal of
Oral Science & Rehabilitation
[33] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
Figs. 3 & 4
Fig. 3
Biopsy at 8 weeks of an implant
placed at the crestal level.
Slight resorption of the
vestibular wall was observed,
with stable and thick soft
tissue.
Fig. 4
Biopsy at 8 weeks of an implant
placed at the subcrestal level.
Slight resorption of the
vestibular wall with neoformed
bone was observed around
the implant neck, with stable
and thick soft tissue.
Figs. 5 & 6
Fig. 5
Bone–implant contact at 12
weeks in unloaded bone. The
bone was in intimate contact
with the BIOETCH surface.
Fig. 6
Biopsy at 12 weeks of an
implant placed at the crestal
level. Remodeling of the buccal
and lingual walls with
neoformed bone around the
implant neck was observed.
Figs. 7 & 8
Fig. 7
Biopsy at 12 weeks of an
implant placed at the
subcrestal level. Remodeling
of the vestibular and lingual
walls with a large amount of
neoformed bone protecting the
implant neck was observed.
Fig. 8
Bone–implant contact at 8
weeks in healed bone. The
bone was in intimate contact
with the BIOETCH surface.
Table 1
Implant placement
(healing period)
V-L
(mean ± SD)
A-B
(mean ± SD)
A-Bc
(mean ± SD)
A-L
(mean ± SD)
A-Lc
(mean ± SD)
Crestal (8 weeks)
0.58 ± 0.30
1.83 ± 0.40
1.33 ± 0.50
0.45 ± 0.70
1.24 ± 0.70
Subcrestal (8 weeks)
0.64 ± 0.50
1.44 ± 0.90
1.22 ± 0.70
0.67 ± 0.70
1.52 ± 0.50
Crestal (12 weeks)
0.83 ± 0.30
1.26 ± 0.70
1.69 ± 0.30
0.88 ± 0.80
1.22 ± 0.70
Subcrestal (12 weeks)
0.84 ± 0.10
1.31 ± 0.50
1.57 ± 0.10
0.33 ± 0.80
0.98 ± 0.90
p value
0.7219
0.0345
0.1281
0.0235
0.0122
Level of significance
p > 0.05
p < 0.05*
p < 0.05*
p < 0.05*
p < 0.05*
V-L = difference between the buccal bone crest and the lingual bone crest;
SD = standard deviation;
A-B = distance from the top of the implant neck to the buccal bone crest;
A-Bc = distance from the top of the implant collar to the first BIC
at the buccal aspect;
A-L = distance between the top of the implant collar and the lingual bone crest;
A-Lc = distance from the top of the implant collar to the first BIC
at the lingual aspect;
* indicates statistical significance.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 33
Table 1
Mean values (mm) ± standard
deviation mm for the Brunner
and Langer test (nonparametric analysis of repeated
measures). Description
of the data in healed bone.
[34] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
Table 2
Crestal
Subcrestal
Mean ± SD
p value
Significance
Mean ± SD
p value
Significance
8 weeks
35.22 ± 0.87
0.4333
p > 0.05
47.22 ± 0.87
0.324
p < 0.05*
12 weeks
41.52 ± 0.11
0.0231
p > 0.05*
54.87 ± 0.23
0.012
p < 0.05*
Table 3
Implant
placement
(healing period)
PM-IS BC
PM-IS LC
IS BC
IS-LC
BC-LC
Mean ± SD
Median
Mean ± SD
Median
Mean ± SD
Median
Mean ± SD
Median
Mean ± SD
Median
Crestal
(8 weeks)
3.20 ± 0.12*
3.2
2.92 ± 0.46*
2.9
2.17 ± 0.90
2.1
1.78 ± 0.80
1.7
1.61 ± 0.80
1.6
Subcrestal
(8 weeks)
2.10 ± 0.16*
2.0
2.88 ± 0.90*
2.8
1.80 ± 0.40
1.7
1.60 ± 0.10
1.6
1.40 ± 0.90
1.4
Crestal
(12 weeks)
2.70 ± 0.82*
2.7
3.12 ± 0.18*
3.0
1.99 ± 0.60
1.9
1.72 ± 0.30
1.7
1.61 ± 0.60
1.6
PM-IS BC = distance from the periimplant mucosa to the buccal bone crest;
PM-IS LC = distance from the periimplant mucosa to the lingual bone crest;
IS-BC = distance from the top of the implant shoulder to the first BIC at the buccal aspect;
Table 2
Mean values of BIC % ±
standard deviation at the
different time periods.
Description of the data in
healed bone.
Table 3
Brunner and Langer test (nonparametric repeated measures
analysis of variance) applied
to mean values ± standard
deviation and median values
(mm) related to implants
placed subcrestally. The level
of significance was set at
p < 0.05.
IS-LC = distance from the top of the implant shoulder to the lingual bone crest;
BL-LC = difference between buccal bone crest and lingual bone crest;
SD = standard deviation; * indicates statistical significance.
Moreover, the delicate marginal portion of the
buccal bone wall frequently contains proportionally larger amounts of bundle bone than the lingual wall does.11 Bundle bone is a tooth-related
tissue that, after tooth loss, will model and eventually disappear.4, 5
In the present study, BIC values decreased in
the subcrestal group from the healing period of
8 weeks to the 12-week healing period in implants
placed in healed bone. This finding corroborates
that of Araújo et al.6, 7 The authors concluded that
the BIC established during the early healing phase
after implant insertion was partially lost when
the buccal bone wall was resorbed. The gaps
between the implant and the walls of the alveoli
for immediate post-extraction implants were
filled with bone tissue after the 8-week healing
period. In the present study, a more coronal BIC
was obtained in the test group (subcrestal). The
total BIC revealed higher values in the subcrestal
group. The higher BIC values of the test group
after 8 and 12 weeks of healing suggest that bone
regeneration may be more favorable for implants
placed subcrestally, which is in agreement with
results reported by other authors.55 Therefore,
subcrestal insertion of dental implants may facilitate anterior BIC at the implant neck. It was also
observed that a comparatively larger portion of
the implant surface was in direct contact with
the bone within the defect area after a period of
12-week wound healing for the control and test
implants compared with the 8-week healing
34 Volume 3 | Issue 3/2017
period. This is in accordance with previous articles published by other authors.55 They concluded that higher BIC values were found after 3
months of healing, compared with results after
1 month of healing.
The present study demonstrated that,
regardless of the vertical positioning, subcrestal
placement (test group) and crestal placement
(control group) showed similar outcomes and
bone resorption patterns, with minor differences
between them.
The buccal and lingual BIC values were always
higher for the subcrestal implants. Therefore, for
these measurements, more favorable results
should be obtained with subcrestal placement of
implants. Clinically, implants are often inserted
at crestal bone level.13, 14 However, implants can
be inserted subcrestally in esthetic areas to minimize the risk of exposure to metals and to allow
sufficient space in the vertical dimension to
develop an adequate emergence profile.24, 38, 39
The modeling in the marginal defect region was
accompanied by marked attenuation of the
dimensions of both the delicate buccal and the
wider lingual bone walls. At the buccal aspect,
this resulted in some marginal loss of osseointegration.6, 7 In this regard, Caneva et al. suggested
that implants should be placed 1 mm subcrestally
to reduce or eliminate exposure of the rough portion of the implant above the alveolar ridge.24 In
addition, subcrestal placement of an implant may
facilitate BIC earlier at the implant neck.
Journal of
Oral Science & Rehabilitation
[35] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
Conclusion
design of an implant with a smooth neck without
microthreads and with a surface highly receptive
Our findings suggest that less resorption can be to osteoblasts improves osseointegration in the
expected when implants are inserted 2 mm sub- initial stages, which a posteriori increases.
crestally for both immediate and deferred
implants compared with placement at the crestal
level. In addition, higher BIC values were found
Competing interests
at 12 weeks of follow-up in the group of implants
placed subcrestally in healed bone compared The authors declare that they have no competwith those placed subcrestally immediately. The ing interests.
References
1.
Abrahamsson I, Alboury JP, Berglundh T.
Healing at fluoride-modified
implants placed in wide marginal defects:
an experimental study in dogs.
→ Clin Oral Implants Res.
2008 Feb;19(2):153–9. Epub 2007 Nov 26.
9.
Barros RR, Novaes AB Jr, Papapelxiou V.
Buccal bone remodeling after immediate
implantation with a flap or flapless
approach. A pilot study in dogs.
→ Titanium.
2009;1:45–51.
2.
Abrahamsson I, Berglundh T, Linder E,
Lang NP, Lindhe J. Early bone
formation adjacent to rough and turned
endosseous implant surfaces.
An experimental study in the dog.
→ Clin Oral Implants Res.
2004 Aug;15(4):381–92.
10.
Brägger U, Hämmerle CH, Lang NP.
Immediate transmucosal implants using
the principle of guided tissue regeneration
(II). A cross-sectional study comparing
the clinical outcome 1 year after immediate
to standard implant placement.
→ Clin Oral Implants Res.
1996 Sep;7(3):268–76.
3.
Alomrani AN, Hermann JS, Jones AA,
Buser D, Schoolfield J, Cochran DL.
The effect of a machined collar on coronal
hard tissue around titanium implants: a
radiographic study in the canine mandible.
→ Int J Oral Maxillofac Implants.
2005 Sep-Oct;20(5):677–86.
11.
Becker BE, Becker W, Ricci A, Geurs N.
A prospective clinical trial of endosseous
screw-shaped implants placed at the time
of tooth extraction without augmentation.
→ J Periodontol.
1998 Aug;69(8):920–6.
4.
Araújo MG, Lindhe J. Dimensional ridge
alterations following tooth extraction. An
experimental study in the dog.
→ J Clin Periodontol.
2005 Feb;32(2):212–8.
12.
Berglundh T, Abrahamsson I, Lang NP,
Lindhe J. De novo alveolar bone formation
adjacent to endosseous implants.
→ Clin Oral Implants Res.
2003 Jun;14(3):251–62.
5.
Araújo MG, Sukekava F, Wensström JL,
Lindhe J. Ridge alterations following
implant placement in fresh extraction
sockets: an experimental study in the dog.
→ J Clin Periodontol.
2005 Jun;32(6):645–52.
13.
Bornstein MM, Lussi A, Schmid B, Belser
UC, Buser D. Early loading of nonsubmerged titanium implants with a sandblasted
and acid-etched (SLA) surface: 3-year
results of a prospective study in partially
edentulous patients.
→ Int J Oral Maxillofac Implants.
2003 Sep-Oct;18(5):659–66.
6.
Araújo MG, Wennström JL, Lindhe J.
Modeling of the buccal and lingual
bone walls of fresh extraction sites
following implant installation.
→ Clin Oral Implants Res.
2006 Dec;17(6):606–14.
7.
Araújo MG, Sukekava F, Wennström JL,
Lindhe J. Tissue modeling following
implant placement in fresh extraction
sockets.
→ Clin Oral Implants Res.
2006 Dec;17(6):615–24.
8.
Araújo MG, Linder E, Lindhe J. Bio-Oss
collagen in the buccal gap at immediate
implants: a 6-month study in the dog.
→ Clin Oral Implants Res.
2011 Jan;22(1):1–8.
14.
Bornstein MM, Schmid B, Belser UC, Lussi
A, Buser D. Early loading of
non-submerged titanium implants with a
sandblasted and acid-etched surface.
5-year results of a prospective study in
partially edentulous patients.
→ Clin Oral Implants Res.
2005 Dec;16(6):631–8.
15.
Bornstein MM, Valderrama P, Jones AA,
Wilson TG, Seibl R, Cochran DL. Bone
apposition around two different
sandblasted and acid-etched titanium
implant surfaces: a histomorphometric
study in canine mandibles.
→ Clin Oral Implants Res.
2008 Mar;19(3):233–41.
16.
Botticelli D, Berglundh T, Buser D, Lindhe J.
The jumping distance revisited:
an experimental study in the dog.
→ Clin Oral Implants Res.
2003 Feb;14(1):35–42.
17.
Botticelli D, Berglundh T, Lindhe J. The
influence of a biomaterial on the
closure of a marginal hard tissue defect
adjacent to implants. An experimental
study in the dog.
→ Clin Oral Implants Res.
2004 Jun;15(3):285–92.
18.
Botticelli D, Berglundh T, Lindhe J.
Resolution of bone defects of varying
dimension and configuration in the
marginal portion of the peri-implant bone.
An experimental study in the dog.
→ J Clin Periodontol.
2004 Apr;31(4):309–17.
19.
Botticcelli D, Persson LG, Lindhe J,
Berglundh T. Bone tissue formation
adjacent to implants placed in fresh
extraction sockets: an experimental study
in dogs.
→ Clin Oral Implants Res.
2006 Aug;17(4):351–8.
20.
Botticelli D, Berglundh T, Persson LG,
Lindhe J. Bone regeneration at implants
with turned or rough surfaces in
self-contained defects. An experimental
study in the dog.
→ J Clin Periodontol.
2005 May;32(5):448–55.
21.
Buser D, Martin WC, Belser UC. Surgical
considerations for single-tooth
replacements in the esthetic zone:
standard procedures in sites without bone
deficiencies.
→ In: Belser UC, Martin W, Jung R,
Hammerle CH, Schmid B, Morton D,
Buser D, editors. ITI treatment guide.
Vol. 1, Implant therapy in the esthetic zone.
Single-tooth replacements.
Berlin: Quintessence.
2007. p. 26–37.
Journal of
Oral Science & Rehabilitation
22.
Buser D, Chen ST, Weber HP, Belser UC.
Early implant placement following
single-tooth extraction in the esthetic
zone: biologic rationale and surgical
procedures.
→ Int J Periodontics Restorative Dent.
2008 Oct;28(5):441–51.
23.
Calvo-Guirado JL, Ortiz-Ruiz AJ, Negri B,
López-Marí L, Rodríguez-Barba C,
Schlottig F. Histological and histomorphometric evaluation of immediate
implant placement on a dog model with
a new implant surface treatment.
→ Clin Oral Implants Res.
2010 Mar;21(3):308–15.
24.
Caneva M, Salata LA, de Souza SS, Bressan
E, Botticelli D, Lang NP. Hard tissue
formation adjacent to implants of various
size and configuration immediately placed
into extraction sockets: an experimental
study in dogs.
→ Clin Oral Implants Res.
2010 Sep;21(9):885–90.
25.
Cardaropoli G, Lekholm U, Wennström JL.
Tissue alterations at implant-supported
single-tooth replacements: a 1-year
prospective clinical study.
→ Clin Oral Implants Res.
2006 Apr;17(2):165–71.
26.
Cho GC. Evidence-based approach
for treatment planning options for the
extensively damaged dentition.
→ J Calif Dent Assoc.
2004 Dec;32(12):983–90.
27.
Fickl S, Zuhr O, Stein JM, Hürzeler MB.
Peri-implant bone level around implants
with platform-switched abutments.
→ Int J Oral Maxillofac Implants.
2010 May-Jun;25(3):577–81.
28.
Grunder U, Polizzi G, Goene R, Hatano N,
Henry P, Jackson WJ, Kawamura K, Köhler
S, Renouard F, Rosenberg R, Triplett G,
Werbitt M, Lithner B. A 3-year prospective
multicenter follow-up report on the
immediate and delayed-immediate
placement of implants.
→ Int J Oral Maxillofac Implants.
1999 Mar-Apr;14(2):210–6.
Volume 3 | Issue 3/2017 35
[36] =>
Ta p e r e d i m p l a n t s f o r b u n d l e b o n e p r e s e r v a t i o n
29.
Hänggi MP, Hänggi DC, Schoolfield JD,
Meyer J, Cochran DL, Hermann, JS. Crestal
bone changes around titanium implants.
Part I: a retrospective radiographic
evaluation in humans comparing two
non-submerged implant designs with
different machined collar lengths.
→ J Periodontol.
2005 May;76(5):791–802.
30.
Hämmerle CH, Brägger U, Bürgin W,
Lang NP. The effect of subcrestal
placement of the polished surface of ITI
implants on marginal soft and hard tissues.
→ Clin Oral Implants Res.
1996 Jun;7(2):111–9.
31.
Hermann JS, Buser D, Schenk RK,
Higginbottom FL, Cochran DL.
Biologic width around titanium implants.
A physiologically formed and stable
dimension over time.
→ Clin Oral Implants Res.
2000 Feb;11(1):1–11.
37.
Nemcovsky CE, Artzi Z, Moses O, Gelernter
I. Healing of marginal defects at implants
placed in fresh extraction sockets or after
4-6 weeks of healing. A comparative study.
→ Clin Oral Implants Res.
2002 Aug;13(4):410–9.
38.
Negri B, Calvo-Guirado JL,
Ramírez-Fernández MP, Maté Sánchezde Val J, Guardia J, Muñoz-Guzón F.
Peri-implant bone reactions to immediate
implants placed at different levels in
relation to crestal bone. Part II: a pilot
study in dogs.
→ Clin Oral Implants Res.
2012 Feb;23(2):236–44.
39.
Negri B, Calvo-Guirado JL, Pardo-Zamora
G, Ramírez-Fernández MP, Delgado-Ruíz
RA, Muñoz-Guzón F. Peri-implant bone
reactions to immediate implants placed at
different levels in relation to crestal bone.
Part I: a pilot study in dogs.
→ Clin Oral Implants Res.
2012 Feb;23(2):228–35.
32.
Hermann JS, Buser D, Schenk RK,
Schoolfield JD, Cochran DL. Biologic
width around one- and two-piece
titanium implants.
→ Clin Oral Implants Res.
2001 Dec;12(6):559–71.
33.
Iezzi G, Degidi M, Shibli JA, Vantaggiato G,
Piattelli A, Perrotti V. Bone response
to dental implants after a 3- to 10-year
loading period: a histologic and
histomorphometric report of four cases.
→ Int J Periodontics Restorative Dent.
2013 Nov-Dec;33(6):755–61.
34.
Khang W, Feldman S, Hawley CE,
Gunsolley J. A multi-center study
comparing dual acid-etched and
machined-surfaced implants in various
bone qualities.
→ J Periodontol.
2001 Oct;72(10):1384–90.
35.
Lazzara RJ. Immediate implant placement
into extraction sites: surgical and
restorative advantages.
→ Int J Periodontics Restorative Dent.
1989;9(5):332–43.
36.
Le Guéhennec L, Soueidan A, Layrolle P,
Amouriq Y. Surface treatments of titanium
dental implants for rapid osseointegration.
→ Dent Mater.
2007 Jul;23(7):844–54.
40.
Orsini E, Salgarello S, Bubalo M, Lazic Z,
Trire A, Martini D, Franchi M, Ruggeri A.
Histomorphometric evaluation of implant
design as a key factor in peri-implant bone
response: a preliminary study in a dog
model.
→ Minerva Stomatol.
2009 Jun;58(6):263–75.
41.
Paolantonio M, Dolci M, Scarano A,
d’Archivio D, di Placido G, Tumini V, Piattelli
A. Immediate implantation in fresh
extraction sockets. A controlled clinical and
histological study in man.
→ J Periodontol.
2001 Nov;72(11):1560–71.
42.
Piattelli A, Scarano A, Quaranta M.
High-precision, cost-effective cutting
system for producing thin sections
of oral tissues containing dental implants.
→ Biomaterials.
1997 Apr;18(7):577–9.
43.
Piattelli A, Artese L, Penitente E, Iaculli F,
Degidi M, Mangano C, Shibli JA, Coelho
PG, Perrotti V, Iezzi G. Osteocyte density
in the peri-implant bone of implants
retrieved after different time periods
(4 weeks to 27 years).
→ J Biomed Mater Res B Appl Biomater.
2014 Feb;102(2):239–43.
45.
Pontes AE, Ribeiro FS, da Silva VC,
Margonar R, Piattelli A, Cirelli JA,
Marcantonio E Jr. Clinical and radiographic
changes around dental implants inserted in
different levels in relation to crestal bone,
under different restoration protocols, in the
dog model.
→ J Periodontol.
2008 Mar;79(3):486–94.
46.
Sanz M, Cecchinato D, Ferrus J, Pjetursson
EB, Lang NP, Lindhe J. A prospective,
randomized-controlled clinical trial to
evaluate bone preservation using implants
with different geometry placed into
extraction sockets in the maxilla.
→ Clin Oral Implants Res.
2010 Jan;21(1):13–21.
47.
Shalabi MM, Gortemaker A, Van’t Hof MA,
Jansen JA, Creugers NH. Implant surface
roughness and bone healing: a systematic
review.
→ J Dent Res.
2006 Jun;85(6):496–500.
48.
Schropp L, Wenzel A, Kostopoulos L,
Karring T. Bone healing and soft
tissue contour changes following singletooth extraction: a clinical and
radiographic 12-month prospective study.
→ Int J Periodontics Restorative Dent.
2003 Aug;23(4):313–23.
49.
Schwarz F, Alcoforado G, Nelson K, Schaer
A, Taylor T, Beuer F, Strietzel, FP. Impact of
implant-abutment connection, positioning
of the machined collar/microgap, and
platform switching on crestal bone level
changes. Camlog Foundation consensus
report.
→ Clin Oral Implants Res.
2014 Nov;25(11):1301–3.
53.
Tatarakis N, Bashutski J, Wang HL, Oh TJ.
Early implant bone loss: preventable or
inevitable?
→ Implant Dent.
2012 Oct;21(5):379–86.
54.
Terheyden H, Stadlinger B, Sanz M,
Garbe AI, Meyle J. Inflammatory reaction –
communication of cells.
→ Clin Oral Implants Res.
2014 Apr;25(4):399–407.
55.
Tran BH, Chen ST, Caiafa A, Davies HMS,
Darby IB. Transmucosal healing around
peri-implant defects: crestal and
subcrestal implant placement in dogs.
→ Clin Oral Implants Res.
2010 Aug;21(8):794–803.
56.
Trisi P, Lazzara R, Rao W, Rebaudi A.
Bone-implant contact and bone quality:
evaluation of expected and actual bone
contact on machined and osseotite implant
surfaces.
→ Int J Periodontics Restorative Dent.
2002 Dec;22(6):535–45.
57.
Trisi P, Marcato C, Todisco M. Bone-toimplant apposition with machined
and MTX microtextured implant surfaces
in human sinus grafts.
→ Int J Periodontics Restorative Dent.
2003 Oct;23(5):427–37.
50.
Schwartz-Arad D, Chaushu G. Placement
of implants into fresh extraction sites:
4 to 7 years retrospective evaluation of 95
immediate implants.
→ J Periodontol.
1997 Nov;68(11):1110–6.
58.
Weng D, Nagata MJ, Bell M, Bosco AF,
de Melo LG, Richter EJ. Influence of
microgap location and configuration on
the periimplant bone morphology in
submerged implants. An experimental
study in dogs.
→ Clin Oral Implants Res.
2008 Nov;19(11):1141–7.
51.
Schwartz-Arad D, Chaushu G. The ways
and wherefores of immediate placement
of implants into fresh extraction sites:
a literature review.
→ J Periodontol.
1997 Oct;68(10):915–23.
59.
Welander M, Abrahamsson I, Berglundh T.
Placement of two-part implants in
sites with different buccal and lingual bone
heights.
→ J Periodontol.
2009 Feb;80(2):324–9.
44.
Pontes AE, Ribeiro FS, Iezzi G, Piattelli A,
Cirelli JA, Marcantonio E Jr. Biologic
width changes around loaded implants
inserted in different levels in relation
to crestal bone: histometric evaluation
in canine mandible.
→ Clin Oral Implants Res.
2008 May;19(5):483–90.
36 Volume 3 | Issue 3/2017
52.
Spray JR, Black CG, Morris HF, Ochi S. The
influence of bone thickness on facial
marginal bone response: stage 1 placement
through stage 2 uncovering.
→ Ann Periodontol.
2000 Dec;5(1):119–28.
Journal of
Oral Science & Rehabilitation
60.
Niu W, Wang P, Zhu S, Liu Z, Ji P. Marginal
bone loss around dental implants with
and without microthreads in the neck: a
systematic review and meta-analysis.
→ J Prosthet Dent.
2017 Jan;117(1):34–40.
[37] =>
Journal of
Oral Science
&
Rehabilitation
€50/issue of the Journal
(4 issues/year; including
VAT and shipping costs,
for a total of €200/year)
I S S N 2 3 6 5 - 6 1 2 3 (Print)
Dental Tribune
International GmbH,
Holbeinstr. 29, 04229
Leipzig, Germany.
Volume 3 — Issue 3/2017
Your subscription will be
renewed automatically
every year until a written
cancellation is sent
six weeks prior to the
renewal date to
I S S N 2 3 6 5 - 6 8 9 1 (Online)
Journal for periodontology, implant dentistry,
dental prosthodontics and maxillofacial surgery
Subscribe Now!
Shipping address
City
Country
Phone
Fax
Signature
Date
PayPal | subscriptions@dental-tribune.com
Credit card
Credit card number
Expiration date
fax: +49 341 4847 4173 | email: subscriptions@dental-tribune.com
Security code
[38] =>
Fully digital workflow
Improved fully digital workflow to rehabilitate an
edentulous patient with an
implant overdenture in
4 appointments: A case report
Abstract
Background
Marco Tallarico,a Danilo Schiappa,b Franco Schipani,c
Fabio Cocchi,d Marco Annuccie & Erta Xhanarif
a
Aldent University, Tirana, Albania; private practice,
Rome, Italy
b
Private practice, Fondi, Italy
c
Private practice, Bologna, Italy
d
Private practice, Modena, Italy
e
Private practice, Rome, Italy
f
Private practice, Tirana, Albania
Corresponding author:
Dr. Marco Tallarico
Via di Val Tellina 116
00151 Rome
Italy
T +39 328 075 8769
me@studiomarcotallarico.it
The digital revolution is changing the world, and dentistry is no exception.
Through the development of new equipment and workflows, the diagnosis and treatment of patients are becoming simpler and more efficient.
However, a fully digital approach to treating edentulous patients may be
a challenge and time-consuming, because edentulous sites are often flat
and smooth, with few features.
Case presentation
This clinical case presentation demonstrates step by step a fully digital
workflow to rehabilitate a 67-year-old edentulous patient with a removable complete dental prosthesis. Treatment included cone beam computed tomography scan taken according to a modified double-scan protocol, existing removable complete dental prosthesis digitalization,
computer-guided template-assisted implant placement, an optical
impression taken with a modified template, a CAD/CAM titanium bar
and a cobalt–chromium, friction fit superstructure framework.
How to cite this article:
Tallarico M, Schiappa D, Schipani F, Cocchi F, Annucci M,
Xhanari E. Improved fully digital workflow to
rehabilitate edentulous patient with an implant
overdenture in 4 appointments: A case report.
J Oral Science Rehabilitation.
2017 Sep;3(3):38–46.
Conclusion
A fully digital workflow was effective in restoring function and esthetics
in an edentulous male patient treated with an overdenture fully supported
by four implants and a CAD/CAM titanium bar with a low-profile attachment system.
Keywords
Intraoral scanner, digital impression, guided surgery, accuracy, dental
implants, overdenture.
38 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[39] =>
Fully digital workflow
Introduction
technique to take an accurate intraoral optical
impression of edentulous patient is described.
Prosthetic-driven implant placement is a key
factor for successful implant therapy.1–4 Hence,
computer-assisted template-based implant
placement has become increasingly popular
owing to improved planning and the higher
transfer accuracy of the virtual plan to the surgical site compared with freehand insertion or
freehand final drilling.5 Nevertheless, the accuracy of computer-assisted template-based
implant placement depends on several factors,
from data set acquisition to the surgical procedure. Originally, guided surgery protocols
advocated a dual-scan protocol.6 Today, the
continuous technological progress in both
computer-based development and the dental
manufacturing process offers additional instruments for treatment planning, surgical placement and prosthetic rehabilitation in an interdisciplinary team approach.
An accurate fit of the implant master cast
affects the passive fit of an implant-supported
fixed complete dental prosthesis.7 Thus, an accurate implant impression is a prerequisite for fabricating an accurate master cast and therefore
an accurately fitting prosthesis.8 There are various implant impression techniques that have
been utilized to fabricate a definitive cast for the
production of an accurately fitting implantsupported fixed complete dental prosthesis.8, 9
In a recent randomized controlled trial, it was
concluded that the clinical outcome of plaster
impressions for completely edentulous patients
was found to be the same as for splinted polyvinyl siloxane impressions.8 Today, there is no
doubt about the potential of recent intraoral
optical impression systems available on the
market regarding diagnosis and treatment planning, as well as for the fabrication of fixed dental
prostheses. Their accuracy compares well with
traditional impression taking.10 Moreover, intraoral scanners have been successfully used in the
fabrication of partial11, 12 and removable complete
dental prostheses.13 However, scanning edentulous areas with intraoral scanners may be difficult and time-consuming because edentulous
sites are smooth and devoid of features. Thus,
the fabrication of complete-arch restorations
remains a challenge when data are directly
acquired with an intraoral scanner.
The aim of the present study is to present a
fully digital pathway in a model-free approach
to rehabilitate a maxillary edentulous patient
with an implant overdenture. A newly developed
Case report
A partially edentulous 67-year-old man with a
removable complete dental prosthesis in the
upper jaw and a removable complete partial
prosthesis in the lower jaw was referred to a
private center in Rome, Italy, for a possible maxillary implant-supported rehabilitation. The
patient had been edentulous in the upper jaw
for years. Nevertheless, he had never been comfortable with his maxillary removable complete
dental prosthesis, and he stated that he was
interested in an implant-supported fixed dental
prosthesis.
First clinical appointment
The patient’s medical history was collected and
preoperative photographs, radiographs, periodontal screening and model casts were
obtained for initial evaluation. During the clinical
examination, the existing removable complete
dental prosthesis and functional and esthetic
aspects were evaluated, with particular attention to the fit of the prosthesis, vertical dimension of occlusion, facial support and lip position.
Extraoral examination of the patient without the
existing removable complete dental prosthesis
showed a wide nasolabial angle and insufficient
lip support (Figs. 1 & 2). All treatment options
were then discussed and evaluated together
with the patient. An implant-supported fixed
dental prosthesis was excluded because of the
need for facial support. Hence, a maxillary
implant-supported overdenture was considered
the only possible therapeutic option.
The prosthetic-driven planning workflow
started with a modified double-scan protocol,
with 4–6 drops of flowable composite added to
the existing removable complete dental prosthesis, instead of spherical gutta-percha markers (Fig. 3).6 In this technique, the first scan was
a cone beam computed tomography (CBCT) scan
(CRANEX 3Dx, SOREDEX, Tuusula, Finland) of
the patient wearing the existing removable complete dental prosthesis. A wax bite was used to
separate the dental arches (Fig. 3). The second
scan was only of the existing removable complete dental prosthesis, performed using an
optical intraoral scanner (Carestream Dental,
Atlanta, Ga., U.S.) to allow the merging of the
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 39
[40] =>
Fully digital workflow
Fig. 1
Fig. 2
Fig. 4
Fig. 1
Frontal extraoral view.
Fig. 2
Lateral extraoral view.
Fig. 3
Existing removable complete
dental prosthesis with 6
drops of flowable composite
and a wax bite.
Fig. 4
Optical scanning of the
existing removable complete
dental prosthesis.
Fig. 5
Three-dimensional STL file
of the existing removable
complete dental prosthesis.
Fig. 3
Fig. 5
hexidine (CURASEPT, Curaden Healthcare,
Saronno, Italy) for one min and received prophylactic antibiotic therapy (2 g of amoxicillin or
600 mg of clindamycin if allergic to penicillin).
The accurate fit of the surgical templates was
tried directly in the patient’s mouth (Fit Checker,
GC, Tokyo, Japan). The patient was treated
under local anesthesia using articaine with
1:100,000 epinephrine, administered 20 min
before surgery. The surgical template was stabilized using a silicone surgical index, derived
from the virtual plane, and five preplanned
anchor pins (New Ancorvis). Planned implants
(Osstem TSIII) were placed flapless using dedicate drills (OsstemGuide KIT, Osstem; Fig. 9).
All of the implants were inserted with a minimum insertion torque of 35 N cm according to
previously published protocols.14 Preplanned
multiunit abutments were immediately screwed
on to the implants (New Ancorvis) and never
removed. Immediately after implant placement,
the patient received a digital impression
(CS 3600 intraoral scanner, Carestream Dental),
taken at abutment level, using dedicate
scan abutments (Type AQ, New Ancorvis;
Second clinical appointment
Figs. 10a & b). In order to improve the accuracy
of the digital impression in a fully edentulous
One hour before implant placement, the patient patient, a second digital impression was taken
underwent professional oral hygiene, used a using a dedicate opaque template, made by virprophylactic antiseptic containing 0.2% chlor- tual planning, that was stabilized in the patient’s
DICOM data with the STL file (Figs. 4 & 5). Using
reverse engineering, a virtual model was
achieved (Fig. 6).
The STL and DICOM data were imported into
a 3-D software planning program (3Diagnosys,
Version 4.2, 3DIEMME, Cantù, Italy). The reprocessed surface extrapolated from the DICOM
data and the surface of the existing removable
complete dental prosthesis generated by the
scanning process were merged with the bestfitting repositioning tools of the software
(3Diagnosys). At this point, four prosthetic-driven
implants with a diameter of 3.5 or 4.5 mm and
a length of 13.0 mm (Osstem TSIII, Osstem,
Seoul, South Korea) were planned, taking into
account the bone quality and quantity, softtissue thickness, anatomical landmarks, and the
type, volume and shape of the final restoration
(New Ancorvis, Bargellino, Italy; Fig. 7). After
careful functional and esthetic evaluation and
final verification, the prosthetic-driven plan was
approved, and a stereolithographic surgical template was fabricated with a newer rapid prototyping technology (New Ancorvis; Fig. 8).
40 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[41] =>
Fully digital workflow
Fig. 6
Fig. 7
Fig. 8
Fig. 9
mouth using the same anchor pin positions of
the surgical guide. This template was customized to maintain the tooth design, but allow the
screwing of the scan abutments (Type AQ;
Fig. 11) so that the new STL file could be superimposed with the previous planning (Fig. 12).
Finally, the multiunit abutments were covered
with dedicate caps, and the existing removable
complete denture was relined at chairside with
a autopolymerizing resin (Hydro-Cast, Sultan
Healthcare, York, Pa., U.S.), thereby ensuring no
pressure on the healing abutments. After
implant placement, the patient received oral and
written recommendations about medication,
oral hygiene maintenance and diet.
A CAD/CAM titanium bar was anatomically
designed by an experienced dental technician
and CAD designer (MA) according to the implant
position and the shape and volume of the existing removable complete dental prosthesis
(exocad DentalCAD, Engine Build 6136, exocad,
Darmstadt, Germany; Fig. 13).15 Three threadable low-profile attachments (OT Equator,
Rhein'83, Bologna, Italy) and two spheres
(Rhein'83) were planned along the implant bar
(Fig. 14). A cobalt–chromium alloy framework
was then directly designed on to the CAD/CAM
titanium bar project (Fig. 15) according to the
existing tooth setup (exocad Partial Framework
CAD, Version 0.x, exocad). The designs of the
virtual bar and the superstructure framework
were transmitted to the production center (New
Ancorvis), where a one-piece titanium bar was
milled from a homogenous solid block of medical titanium alloy (Ti6Al4V), while the cobalt–
chromium, friction fit superstructure framework
was laser melted (Fig. 16).
Third clinical appointment
The fit of the implant bar and the superstructure
framework was clinically and radiographically
tested in the patient’s mouth according to established criteria (Figs. 17 & 18).16, 17 An interocclusal
record was taken in centric relation, and master
models, fabricated using rapid prototyping techniques, with specially designed implant replicas,
were mounted in a fully adjustable articulator
(PROTARevo 7, KaVo Dental, Biberach, Germany;
Fig. 19). Digital analysis of movement was performed using the ARCUSdigma device (KaVo
Dental) to ascertain and document all the settings required for programming the articulator
(e.g., condylar inclination, Bennett angle, immediate side shift and shift angle). Finally, the
overdenture was finished using a silicone index
derived from the existing removable complete
dental prosthesis as tooth reference, and the
borders sealed to minimize food impaction, and
saliva or air leakage.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 41
Fig. 6
Virtual model derived from the
scan of the existing removable
complete dental prosthesis.
Fig. 7
Prosthetic-driven virtual
implant planning.
Fig. 8
Surgical template.
Fig. 9
Implants placed flapless using
the surgical template.
[42] =>
Fully digital workflow
Figs. 10a & b
Figs. 10a & b
Scan abutment screwed to
the multiunit abutments (a)
and optical intraoral
impression (b).
Fig. 11
Second optical intraoral
impression with a specially
designed template.
Fig. 12
STL file derived from the
second optical intraoral
impression.
a
b
Fig. 11
Fig. 12
Fig. 13
CAD of the titanium bar.
Fig. 14
CAD/CAM titanium bar with
low-profile attachments and
spheres.
Fig. 13
Fig. 14
42 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[43] =>
Fully digital workflow
Fig. 15
Fig. 16
Fig. 17
Fig. 15
CAD of the superstructure
framework.
Fig. 16
Superstructure framework.
Fig. 17
Intraoral try-in of the
CAD/CAM titanium bar.
Figs. 18a & b
Figs. 18a & b
Periapical radiographs
showing the perfect
fit between the CAD/CAM
titanium bar and the implants
(multiunit abutments).
a
Fig. 19
Implant overdenture
mounted in the fully
adjustable articulator.
b
Fig. 19
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 43
[44] =>
Fully digital workflow
Fig. 20
Fig. 20
Implant overdenture in the
patient’s mouth.
Fig. 21
Dental panoramic tomogram
after prosthesis delivery.
Fig. 21
Fourth clinical appointment
Discussion
The titanium bar was screwed at the abutment
level according to the manufacturer’s instructions and the implant overdenture was delivered
6 weeks after the first visit (Figs. 20 & 21). The
patient was enrolled in a standard implant recall
program. Oral hygiene maintenance was
checked and radiographs were taken early after
final prosthesis delivery. Occlusion was checked
at every appointment.
This clinical report describes a new technique
for fabricating a maxillary implant-supported,
removable complete dental prosthesis using an
intraoral digital scanner to register implant positions and soft-tissue morphology. The main
limitation of the present study is that a single
case report is not suitable for representative
population samples; thus, findings from a case
report cannot be generalized. A second limita-
44 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[45] =>
Fully digital workflow
tion could be an over interpretation of the
results. Hence, these results should be interpreted with caution, since the literature presents
a lack of scientific evidence. Nevertheless, a case
report represents a means of detecting new
techniques, due to the time from observation to
publication, much shorter than for other kinds
of studies.
Existing technologies such as CBCT, in conjunction with virtual 3-D reconstruction of
implant placement and fabrication of surgical
templates with stereolithography, are used in
both treatment planning and implant placement.
However, errors of 1.5 mm and 1.0 mm have been
reported in horizontal and vertical dimensions
for the CBCT technique.18, 19 Furthermore, CBCT
images are subject to severe contamination from
scatter signals that induce large image artifacts,
which limit the applications of CBCT. 20 In order
to overcome the drawbacks related to CBCT
technologies, the existing removable complete
dental prosthesis was digitalized using a more
accurate intraoral scanner.21
The use of intraoral scanners in dental clinics
for taking digital impressions of teeth and
implants is rapidly growing, improving workflow
with other digital technologies. Optical impressions are more comfortable for the patient and
less time consuming. At the same time, they are
accurate and easier for the clinician.22–28 A recent
systematic literature review and meta-analysis
by Chochlidakis et al. concluded that intraoral
scanners can be safely used for taking impressions of single and multiple abutments in dentate patients.23 However, there is still a lack of
evidence on the possibility of using intraoral
scanners to take impressions for long-span restorations or in the case of fully edentulous
patients.9 In a recent in vitro study by Imburgia
et al., the CS 3600 had the best performance in
terms of trueness and precision in both partially
and fully edentulous models with 6 implants.21
Mangano et al., in another in vitro study, found
no differences in trueness and precision between
partially and fully edentulous models.22 However, this result may be due to the fact that the
3-D surface models of the partially edentulous
patient were not cut and trimmed and the
related calculations were consequently performed on the whole arch.
In the present study, in addition to the digital
data acquisition of soft-tissue morphology and
implant positions, a second optical impression
was taken with a specially designed opaque template in conjunction with the same scan abutments (New Ancorvis) to acquire accurate digital data at the implant level in a completely
edentulous patient, as if the patient was partially
edentate. This technique may allow the avoidance of one appointment needed to try a segmental verification device to confirm implant
analogue positions.29
The presented technique uses CAD/CAM
technology with a subtractive manufacturing
process to fabricate a milled bar (infrastructure
framework) and an additive process to fabricate
a friction fit superstructure framework. This digital restorative pathway may decrease patient
discomfort and reduce the labor associated with
fabricating implant-supported, removable complete dental prostheses. According to previously
published prospective studies, the overdenture
fully supported by four implants and a CAD/CAM
titanium bar with a low-profile attachment
system can be considered an effective and predictable option for patients in both maxilla and
mandible.15, 30 Minimum marginal bone remodeling and technical complications can be
expected, together with good periodontal parameters and patient satisfaction, over time.15, 30
Conclusion
The present case report may encourage the use
of intraoral scanners to take accurate intraoral
optical impressions, even in the case of edentulous patients and according to the presented
protocol. Nevertheless, further randomized controlled trials with larger sample sizes are needed
to confirm the outcomes that emerged from the
present work.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 45
[46] =>
Fully digital workflow
References
1.
Tallarico M, Meloni SM, Canullo L, Xhanari
E, Polizzi G. Guided surgery for
single-implant placement: a critical review.
→ J Oral Science Rehabilitation.
2016 Dec;2(4):8–14.
2.
Polizzi G, Cantoni T, Pasini E, Tallarico M.
Immediate loading of variable-thread
expanding tapered-body implants placed
into maxillary post-extraction or healed
sites using a guided surgery approach: an
up-to-five year retrospective analysis.
→ J Oral Science Rehabilitation.
2016 Sep;2(3):50–60.
3.
Tallarico M, Meloni SM, Canullo L, Caneva
M, Polizzi G. Five-year results of a
randomized controlled trial comparing
patients rehabilitated with immediately
loaded maxillary cross-arch fixed dental
prosthesis supported by four or six
implants placed using guided surgery.
→ Clin Implant Dent Relat Res.
2016 Oct;18(5):965–72.
4.
Pozzi A, Tallarico M, Marchetti M, Scarfo B,
Esposito M. Computer-guided versus
free-hand placement of immediately
loaded dental implants: 1-year post-loading results of a multicentre randomised
controlled trial.
→ Eur J Oral Implantol.
2014 Autumn;7(3):229–42.
5.
Vermeulen J. The accuracy of implant
placement by experienced surgeons:
guided vs freehand approach in a
simulated plastic model.
→ Int J Oral Maxillofac Implants.
2017 Mar-Apr;32(3):617–24.
6.
Van Steenberghe D, Glauser R, Blomback
U, Andersson M, Schutyser F, Pettersson A,
Wendelhag I. Computed tomographic
scan-derived customized surgical template
and fixed prosthesis for flapless surgery
and immediate loading of implants in fully
edentulous maxillae: a prospective
multicentre study.
→ Clin Implant Dent Relat Res.
2005;7 Suppl 1:S111–20.
7.
Jemt T, Hjalmarsson L. In vitro measurements of precision of fit of implant-supported frameworks: a comparison between
“virtual” and “physical” assessments of fit
using two different techniques of
measurements.
→ Clin Implant Dent Relat Res.
2012 May;14 Suppl 1:e175–82.
8.
Pozzi A, Tallarico M, Mangani F, Barlattani
A. Different implant impression techniques
for edentulous patients treated with CAD/
CAM complete-arch prostheses: a
randomised controlled trial reporting data
at 3 year post-loading.
→ Eur J Oral Implantol.
2013 Winter;6(4):325–40.
9.
Papaspyridakos P, Chen CJ, Gallucci GO,
Doukoudakis A, Weber HP, Chronopoulos
V. Accuracy of implant impressions for
partially and completely edentulous
patients: a systematic review.
→ Int J Oral Maxillofac Implants.
2014 Jul-Aug;29(4):836–45.
10.
Amin S, Weber HP, Finkelman M, El Rafie
K, Kudara Y, Papaspyridakos P. Digital vs.
conventional full-arch implant impressions:
a comparative study.
→ Clin Oral Implants Res.
2016 Dec 31. doi:10.1111/clr.12994. [Epub
ahead of print].
11.
Kattadiyil MT, Mursic Z, AlRumaih H,
Goodacre CJ. Intraoral scanning of hard
and soft tissues for partial removable
dental prosthesis fabrication.
→ J Prosthet Dent.
2014 Sep;112(3):444–8.
12.
Wu J, Li Y, Zhang Y. Use of intraoral
scanning and 3-dimensional printing in the
fabrication of a removable partial denture
for a patient with limited mouth opening.
→ J Am Dent Assoc.
2017 May;148(5):338–41.
13.
Fang JH, An X, Jeong SM, Choi BH.
Development of complete dentures based
on digital intraoral impressions—case
report.
→ J Prosthodont Res.
2017 Jun 15. pii: S1883-1958(17)30049-X.
doi:10.1016/j.jpor.2017.05.005. [Epub
ahead of print].
14.
Tallarico M, Meloni SM. Open-cohort
prospective study on early implant failure
and physiological marginal remodeling
expected using sandblasted and
acid-etched bone level implants featuring
an 11° Morse taper connection within one
year after loading.
→ J Oral Science Rehabilitation.
2017 Mar;3(1):68–79.
15.
Tallarico M, Xhanari E, Kadiu B, Scrascia R.
Implant rehabilitation of extremely
atrophic mandibles (Cawood and Howell
Class VI) with a fixed-removable solution
supported by four implants: one-year
results from a preliminary prospective case
series study.
→ J Oral Science Rehabilitation.
2017 Jun;3(1):32–40.
16.
Abduo J, Bennani V, Waddell N, Lyons K,
Swain M. Assessing the fit of implant fixed
prostheses: a critical review.
→ Int J Oral Maxillofac Implants.
2010 May-Jun;25(3):506–15.
17.
Eisenmann E, Mokabberi A, Walter MH,
Freesmeyer WB. Improving the fit of
implant-supported superstructures using
the spark erosion technique.
→ Int J Oral Maxillofac Implants.
2004 Nov-Dec;19(6):810–8.
18.
Jabero M, Sarment DP. Advanced surgical
guidance technology: a review.
→ Implant Dent.
2006 Jun;15(2):135–42.
19.
Loubele M, Bogaerts R, Van Dijck E,
Pauwels R, Vanheusden S, Suetens P,
Marchal G, Sanderink G, Jacobs R.
Comparison between effective radiation
dose of CBCT and MSCT scanners for
dentomaxillofacial applications.
→ Eur J Radiol.
2009 Sep;71(3):461–8.
20.
Niu T, Zhu L. Overview of x-ray scatter in
cone-beam computed tomography and its
correction methods.
→ Curr Med Imaging Rev.
2010;6(2):82–9.
21.
Imburgia M, Logozzo S, Hauschild U,
Veronesi G, Mangano C, Mangano FG.
Accuracy of four intraoral scanners in oral
implantology: a comparative in vitro study.
→ BMC Oral Health.
2017 Jun 2;17(1):92. doi:10.1186/
s12903-017-0383-4.
22.
Mangano FG, Veronesi G, Hauschild U,
Mijiritsky E, Mangano C. Trueness and
precision of four intraoral scanners in oral
implantology: a comparative in vitro study.
→ PLoS One.
2016 Sep 29;11(9):e0163107. doi:10.1371/
journal.pone.0163107.
23.
Chochlidakis KM, Papaspyridakos P,
Geminiani A, Chen CJ, Feng IJ, Ercoli C.
Digital versus conventional impressions for
fixed prosthodontics: a systematic review
and meta-analysis.
→ J Prosthet Dent.
2016 Aug;116(2):184–90.e12.
46 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
24.
Wismeijer D, Mans R, van Genuchten M,
Reijers HA. Patients’ preferences when
comparing analogue implant impressions
using a polyether impression material
versus digital impressions (intraoral scan)
of dental implants.
→ Clin Oral Implants Res.
2014 Oct;25(10):1113–8.
25.
Joda T, Lenherr P, Dedem P, Kovaltschuk I,
Bragger U, Zitzmann NU. Time efficiency,
difficulty, and operator’s preference
comparing digital and conventional implant
impressions: a randomized controlled trial.
→ Clin Oral Implants Res.
2016 Sep 5. doi:10.1111/clr.12982. [Epub
ahead of print].
26.
Tsirogiannis P, Reissmann DR, Heydecke G.
Evaluation of the marginal fit of
single-unit, complete-coverage ceramic
restorations fabricated after digital and
conventional impressions: a systematic
review and meta-analysis.
→ J Prosthet Dent.
2016 Sep;116(3):328–35.e2.
27.
Almeidae e Silva JS, Erdelt K, Edelhoff D,
Araújo É, Stimmelmayr M, Vieira LC, Güth
JF. Marginal and internal fit of four-unit
zirconia fixed dental prostheses based on
digital and conventional impression
techniques.
→ Clin Oral Investig.
2014;18(2):515–23.
28.
Ender A, Zimmermann M, Attin T, Mehl A.
In vivo precision of conventional and digital
methods for obtaining quadrant dental
impressions.
→ Clin Oral Investig.
2016 Sep;20(7):1495–504.
29.
Lin WS, Chou JC, Metz MJ, Harris BT,
Morton D. Use of intraoral digital scanning
for a CAD/CAM-fabricated milled bar and
superstructure framework for an
implant-supported, removable complete
dental prosthesis.
→ J Prosthet Dent.
2015 Jun;113(6):509–15.
30.
Pozzi A, Tallarico M, Moy PK. Four-implant
overdenture fully supported by a
CAD-CAM titanium bar: A single cohort
prospective 1-year preliminary study.
→ J Prosthet Dent.
2016 Oct;116(4):516–23.
[47] =>
Please join us!!
Official language : English
[48] =>
Cross-arch implant-supported fixed restoration
Thirteen-year follow-up of a cross-arch
implant-supported fixed restoration in a
patient with generalized aggressive
periodontitis and parafunctional habits
Abstract
Background
David Frencha & Erta Xhanarib
a
b
Private practice, Calgary, Alberta, Canada
Aldent University, Tirana, Albania
Corresponding author:
As implant treatment becomes part of mainstream dental therapy, dental
offices should implement protocols for individualized, systematic and
continuous supportive care of the periimplant tissue. This article describes
the 13-year management of a patient with generalized aggressive periodontitis and bruxism treated using Brånemark TiUnite implants with
machined collars.
Dr. David French
3625 Shaganappi Trail Nw Suite 212
Calgary, AB T3A 0E2
Canada
T +1 403 247 8657
drfrench@shaw.ca
How to cite this article:
French D, Xhanari E. Thirteen-year follow-up of a
cross-arch implant-supported fixed restoration
in a patient with generalized aggressive periodontitis
and parafunctional habits.
J Oral Science Rehabilitation.
2017 Sep;3(3):48–55.
Materials and methods
In the upper jaw, a cross-arch implant-supported fixed restoration was
delivered. In the lower jaw, an implant-supported fixed partial prosthesis
was provided, retaining some natural dentition, which increased the risk
of a periodontal reservoir. Treatment included multiple extractions and
submerged implants. Implant survival rate, patient satisfaction, marginal
bone maintenance and soft-tissue condition at the modified titanium surfaces of the dental implants were evaluated up to 13 years of function.
Results
Two adjacent implants were lost 3 years after loading owing to periimplantitis and these were not replaced. One implant had bone loss after
recementation and retained cement that subsequently responded to intervention with bone recovery. Furthermore, the maxillary prosthesis was
remade once after 3 years of function, owing to porcelain breakage in the
esthetic zone.
Conclusion
This clinical case may provide information about benefits of a long-term
patient history follow-up, with emphasis on periodontal and occlusal risks.
A comprehensive diagnosis, multifactorial approach, good clinician–
patient relationship and vigilant maintenance of oral hygiene were needed
in order to ensure an optimal treatment and a successful long-term result.
Keywords
Dental implants, long-term follow-up, periodontally compromised
patients, periodontitis, supportive periodontal therapy.
48 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[49] =>
Cross-arch implant-supported fixed restoration
Introduction
Endosseous dental implants have been widely
used to aid the support of restorations replacing
missing teeth. This has been widely reported in
the literature dating back to the early 1960s.1, 2
Implants have added predictable treatment
options for patients, clinicians and dental technicians.3, 4 Nevertheless, technical and biological
complications may occur either at an early stage,
owing to failed integration during healing, or
later, regarded as loss of integration and stability after healing and during functional loading.5
Smoking, low bone density, irradiation, infection,
relative overload, previous periodontitis and
parafunctional habits, such as bruxism, are some
of the described risk factors that may lead to
implant failure.5, 6 In the case of parafunctional
habits, in a systematic review, it was noted that
treated patients with periodontitis may experience more implant loss and biological complications compared with nonperiodontitis patients
with implants.4 During the first year of function,
a certain amount of physiological marginal bone
loss is often observed around a dental implant,
and this probably reflects remodeling/adaptation after surgery7 and during loading;8 thereafter, minimal further bone loss has been annually
observed.6, 9 As a consequence, the prerequisites
for implant success are marginal bone loss of up
to 1.0 mm within the first year of implant loading and successive annual mean marginal bone
loss of 0.2 mm during the follow-up period.9, 10
Continuous bone loss with clinical signs of infection, such as bleeding and suppuration, is
referred to as periimplantitis, irrespective of the
sequence of events.11 Depending on the definition used, the prevalence of progressive bone
loss/periimplantitis in long-term studies has
been reported to range from 7.7 to 39.7%.12 Periodontally healthy patients and patients with
chronic adult periodontitis show no difference
in periimplant variables and implant survival
rate, but patients with generalized aggressive
periodontitis have greater periimplant pathology, more marginal bone loss and a lower
implant survival rate.13 Furthermore, it is of interest to note that the impact of a history of periodontitis on early implant loss was found to be
negligible in patients that have been treated with
supportive periodontal therapy.14 However, in
the long term, periimplantitis was detected more
than twice as frequently in periodontally compromised than in periodontally healthy subjects.13, 15
Furthermore, based on clinical experience, it has
been noted that bruxers are a high-risk category
regarding successful implant outcomes and this
has been reported in the literature.15 Studies
have reported more frequent technical complications, including implant loss, in bruxers.16
This case report describes the 13-year management of a patient with generalized aggressive
periodontitis and bruxism treated using Brånemark TiUnite implants (Nobel Biocare, Yorba
Linda, Calif., U.S.) with machined collars. In the
upper jaw, a cross-arch implant-supported fixed
restoration was delivered. In the lower jaw, an
implant-supported fixed partial prosthesis was
provided, retaining some natural dentition, which
increased the risk of a periodontal reservoir.
Case report
A 57-year-old woman with a history of generalized aggressive periodontitis presented to our
clinic for a periodontal consult and treatment in
2003. Despite an overall full-mouth root planing,
multiple surgeries and antibiotics, the patient
continued to exhibit progressive bone loss. Two
years after the initial consult, a comprehensive
clinical, radiographic and study cast evaluation
found that the remaining dentition showed recurrent abscesses with progressive bone loss due to
chronic periodontal disease (Fig. 1). Furthermore,
the case was complicated by pathological tooth
mobility, furcation involvement at the maxillary
molars, occlusal instability and parafunctional
habits, including bruxism.
Various treatment options were discussed
with the patient, including maxillary and mandibular conventional removable complete dentures, as well as implant-supported overdenture
or implant-supported fixed restorations. The
patient’s chief desire was to replace her existing
teeth with implant-supported fixed restorations
without conventional removable complete dentures or removable prostheses. After detailed
consultation, the extraction of all of the remaining maxillary dentition and its replacement with
dental implants were suggested. The patient
understood and agreed to the treatment plan and
was informed about the higher risk of implant
failure owing to her periodontal disease and bruxism, especially if some natural teeth were
retained. The standard outcome in these cases
is up to 98.05% at the 10-year follow-up,17 but
owing to the pre-existing periodontal disease and
bruxism, the success rate was expected to be
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 49
[50] =>
Cross-arch implant-supported fixed restoration
Fig. 1
Pretreatment photograph:
frontal view.
Fig. 2
Implants placed in the upper
jaw after the second-stage
surgery.
Fig. 3
Implants placed in the lower
jaw after the second-stage
surgery.
decreased to 90% at the 10-year follow-up.12, 13
The outcome would be dependent on the patient’s
daily routine, home care and professional recall
visits. The patient decided to proceed with rehabilitation of the upper arch with a fixed complete
denture, being aware of the associated cost,
advantages and disadvantages. Comprehensive
clinical, radiographic and study cast evaluation
found that the previously placed implant in the
maxilla (TiUnite machined collar Brånemark
System MkIII, Nobel Biocare), inserted in the left
central area to restore a tooth lost to an endodontic fracture complication in 1999, could be maintained for planned rehabilitation.
Three months after removal of the teeth and
residual ridge healing, 7 Biocare replace implants
(Nobel Biocare) were placed in additional sites
across the maxillary arch. Simultaneously,
extractions were performed of the mobile
teeth in the right mandibular posterior site.
Four months after extraction, 3 Biocare replace
implants were placed to replace the extracted
teeth. Bone grafting was not required for all
procedures. All of the placed implants achieved
stability at placement and were fully osseointegrated, evidenced by radiography and clinical
torque testing to 35 N cm, performed 3 months
after insertion, during healing abutment connections (Figs. 2 & 3). Finally, the case was
referred to a prosthodontist for full-arch upper
fixed-removable and partial-arch fixed tooth
form prostheses. All efforts were made to retain
some access for a proxy brush under the prosthesis to reduce the periimplantitis risk. The
maxillary and mandibular prostheses were
seated with custom titanium abutments using
a temporary cement (Improv Temporary Implant
Cement, Salvin Dental Specialities, Charlotte,
N.C., U.S.). The patient had regular visits for
periodontal control and maintenance in a
well-organized scheme with appointments over
the years.
The maxillary prosthesis was remade once
after 3 years of function, owing to porcelain
breakage in the esthetic zone. However, after
the remake, the patient improved compliance
regarding use of the bruxism appliance and the
prosthesis remained intact and functional for
over 11 years.
Nevertheless, there was progressive bone
loss at a Class 3 furcation site of the mandibular first molar (Fig. 4) that responded to root
resection therapy in 2003 and remained stable
thereafter (Fig. 5). The overall reduced periodontal disease activity may in part be due to
50 Volume 3 | Issue 3/2017
Fig. 1
Fig. 2
Fig. 3
the extraction of most of the involved teeth and
in part to long-term therapy with a daily dose
of 100 mg of minocycline for acne, begun by the
patient in 2004, then switched in 2008 to
100 mg of doxycycline, cut into quarters and
taken daily. Despite her progressive periodontal
history, the bone loss at the implants showed
the typical pattern of about 0.5 mm of bone loss
beyond the machined collar and at most sites
there was no sign of periimplantitis related to
marginal bone loss. However, there were two
sites in the left maxillary molar area where
periimplant bone loss had developed. The
implants placed at this position were both lost
after 3 years of loading, primarily related to
implant proximity between them, limiting
proper oral hygiene access (Figs. 6 & 7). These
implants were not replaced and the prosthesis
was retained with a distal cantilever pontic at
the first molar area off the most distal implant
site at the second premolar area in the full-arch
prosthesis. Acute suppuration and about 2 mm
Journal of
Oral Science & Rehabilitation
[51] =>
Cross-arch implant-supported fixed restoration
Fig. 4
Fig. 5
Fig. 4
Teeth affected by periodontitis
in the left lower jaw.
Fig. 5
Root resection therapy
performed on the left
mandibular first molar.
Fig. 6
The 2 implants in the left
upper jaw affected
by periimplantitis.
Fig. 6
Fig. 7
Removal of the implants.
Fig. 7
Fig. 8
Periimplant bone loss at the
left mandibular second molar.
Fig. 9
The left mandibular
second molar site shown
fully recovered.
Fig. 8
Fig. 9
of periimplant bone loss were also observed at
the 6-year follow-up at the right mandibular
second molar implant (Fig. 8), related to
retained cement that was noted about 6 months
after a recementation of the splinted crowns. A
flap was raised at the right mandibular molar
area, then the exposed TiUnite surface was
decontaminated with citric acid and hard-tissue
defect walls and soft-tissue excess were
reduced as part of flap closure. At the 7-year
follow-up examination, subgingival irrigation
with minocycline hydrochloride microspheres
(Arestin, OraPharma, Valeant Pharmaceuticals
International, Laval, Quebec, Canada) was performed. At the year 8 visit, the right mandibular
second molar site had fully recovered bone reformation (Fig. 9). Although the patient had
active periodontal disease activity, good clinical
(Figs. 10 & 11) and radiographic (Fig. 12) outcomes were illustrated at the 8-year follow-up
visit, owing to the impact of supportive periodontal therapy.
At the year 13 visit, the second molar still
remained stable in response to intervention,
with a full recovery of historic bone loss that
was once about 2 mm beyond the machined
collar. Good clinical (Figs. 13 & 14) and radiographic (Figs. 15a & b) outcomes were recorded
at the 13-year follow-up visit, owing to good
oral hygiene maintenance and regular recall.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 51
[52] =>
Cross-arch implant-supported fixed restoration
Fig. 10
Fig. 11
Fig. 12
Fig. 10
New prosthesis and follow-up
after 8 years: right side view.
Fig. 11
New prosthesis and follow-up
after 8 years: frontal view.
Fig. 12
New prosthesis and follow-up
after 8 years: radiographs.
Fig. 13
Follow-up after 13 years:
frontal view.
Fig. 14
Fig. 14
Follow-up after 13 years:
right side view.
Fig. 13
Discussion
Little is known about the long-term outcome of
implants with oxidized surfaces, especially in
periodontitis-susceptible patients. The management of this case presented a challenge to the
treating clinician, as the patient presented with
generalized aggressive periodontitis complicated by bruxism. Supportive periodontal control and maintenance following a predesigned
subject-tooth, implant site risk assessment
52 Volume 3 | Issue 3/2017
method is of key importance for long-term success after periodontal surgery.18, 19 The two
implant losses at the 3-year time point were in
accordance with the literature finding that
patients with a history of generalized aggressive
periodontitis are more clearly prone to late failure rates, even when minimally rough implants
are used when periodontal therapy is followed.20
Complicating factors such as implant proximity
and retained cement may have been the initiating factors.
Journal of
Oral Science & Rehabilitation
[53] =>
Cross-arch implant-supported fixed restoration
Fig. 15a
Fig. 15a
Radiographic follow-up of the
maxillary molars up to 13
years.
Fig. 15b
Radiographic follow-up of the
right mandibular second molar
from the start of the
periimplantitis up to the 13th
year of follow-up.
2016
Fig. 15b
2009
2010
2013
2011
2016
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 53
[54] =>
Cross-arch implant-supported fixed restoration
Varying degrees of marginal bone loss are normally seen around dental implants, regardless
of all the efforts to eliminate it.21 Maintenance
and improvement of periimplant bone, as well
as the establishment and maintenance of a
soft-tissue barrier around the implant abutment,
are prerequisites for long-term esthetic and
functional success of an implant-supported restoration. 5 However, during clinical function,
some implants may show extensive and sometimes continuous bone loss, whose primary
cause is not well understood. Previous authors
have proposed several factors that may increase
marginal bone loss around dental implants,
including surgical trauma, biological width
establishment, lack of passive fit of the superstructure, implant–abutment microgap and
occlusal overload.21, 22 Continuous bone loss with
clinical signs of infection, such as bleeding and
suppuration, is referred to as periimplantitis,
irrespective of the sequence of events.12 Depending on the definition, the prevalence of continuous bone loss in long-term studies has been
reported to range from 7.7 to 39.7%;12 however,
some authors have regarded this as unrealistically high.10 These figures are mainly based on
implants with a machined and relatively smooth
surface. Today, most implants have some type
of surface treatment to promote a stronger bone
tissue response, such as blasting, etching, anodic
oxidation and combinations of techniques.23, 24
The moderately rough, highly crystalline, and
phosphate-enriched titanium oxide surface of
the TiUnite implants features an increased titanium dioxide layer, a moderately rough microstructure that enlarges the osseointegrable
surface area, and it has been reported to enhance
the adhesion of human osteoblastlike MG-63
cells to titanium without significantly affecting
the pattern of gene expression.23 Concerns have
been raised that bone loss and subsequent exposure of a rough implant surface may facilitate
establishment of a periimplant infection. 24
Though the numbers of longer-term follow-up
are small, positive clinical and radiographic performance of implants with a porous anodized
surface has been reported.18, 24 This contradicts
a short-term animal study that stated that the
porous anodized surface of TiUnite is more susceptible to progressive periimplant loss once
established.25
In the presented case, the patient’s chief
desire was to have her hopeless teeth replaced
with implant-supported fixed restorations,
keeping the remaining teeth. The patient
54 Volume 3 | Issue 3/2017
understood and agreed to the treatment plan
and was informed about the higher risk of
implant failure owing to her periodontal disease.
The outcomes of this case depended on patient
compliance with the periodontal program.
Follow-up and intervention, when indicated, are
important in a case with a history of periodontal
disease. In particular, the good outcome at site
47 demonstrates the benefit of flap intervention
to remove retained cement and, potentially, the
added benefit of subgingival antimicrobial delivery to address periimplantitis and recover lost
radiographic bone despite prior infection and
bone loss. This would suggest that a contaminated microrough surface does not always lead
to progressive bone loss if there is suitable intervention. Also in this case, the usage of the bruxism appliance was critical to reduce potential
biological and technical complications. According to a recent systematic review, bruxism is
unlikely to be a risk factor for biological complications around dental implants, but it is more
likely to be a risk factor for technical complications.16 The caution that is urged when using
implants to support dental prostheses in bruxers
is due to the common fear that bruxism can
cause overloading and may affect osseointegration and/or compromise the integrity of technical components and veneering materials. Keeping this in mind, care must be exercised in
periodic control of occlusal design and presence
of nonaxial loads on implant-supported restorations, and adequate levels of oral hygiene must
be maintained in the long term in order to avoid
increasing the risk of periimplant disease.
Conclusion
Implant treatment in patients exhibiting ongoing
active periodontal disease and bruxism is not
contraindicated provided that adequate infection control and an individualized maintenance
program are assured. The results of this case
illustrated good clinical and radiographic outcomes with long-term prosthetic stability. Confounding factors, such as the minimally rough
surface of the implant, did not seem to cause
bone loss.
Competing interests
The authors declare that they have no competing interests.
Journal of
Oral Science & Rehabilitation
[55] =>
Cross-arch implant-supported fixed restoration
References
1.
Schröder F. Bone and cartilage
reconstructions after use of implants.
→ Trans Int Conf Oral Surg.
1967:398–403.
2.
Cobb Jr. Subperiosteal vitallium implants
in dogs.
→ Oral Surg Oral Med Oral Pathol.
1960 Oct;13:1153–62.
3.
Brånemark PI, Hansson BO, Adell R, Breine
U, Lindström J, Hallén O, Ohman A.
Osseointegrated implants in the treatment
of the edentulous jaw. Experience from a
10-year period.
→ Scand J Plast Reconstr Surg Suppl.
1977;16:1–132.
4.
Adell R, Lekholm U, Rockler B, Brånemark
PI. A 15-year study of osseointegrated
implants in the treatment of the
edentulous jaw.
→ Int J Oral Surg.
1981 Dec;10(6):387–416.
5.
Sennerby L, Roos J. Surgical determinants
of clinical success of osseointegrated
oral implants: a review of the literature.
→ Int J Prosthodont.
1998 Sep-Oct;11(5):408–20.
6.
Albrektsson T, Zarb GA, Worthington P,
Eriksson AR. The long-term efficacy of
currently used dental implants: a review
and proposed criteria of success.
→ Int J Oral Maxillofac Implants.
1986 Summer;1(1):11–25.
7.
Pozzi A, Agliardi E, Tallarico M, Barlattani A.
Clinical and radiological outcomes
of two implants with different prosthetic
interfaces and neck configurations:
randomized, controlled, split-mouth
clinical trial.
→ Clin Implant Dent Relat Res.
2014 Feb;16(1):96–106.
8.
Brånemark PI, Svensson B,
van Steenberghe D. Ten-year survival
rates of fixed prostheses on four or six
implants ad modum Brånemark in full
edentulism.
→ Clin Oral Implants Res.
1995 Dec;6(4):227–31.
9.
Jemt T, Albrektsson T. Do long-term
followed-up Brånemark implants
commonly show evidence of pathological
bone breakdown? A review based on
recently published data.
→ Periodontol 2000.
2008;47:133–42.
10.
Oh TJ, Yoon J, Misch CE, Wang HL.
The causes of early implant bone loss:
myth or science?
→ J Periodontol.
2002 Mar;73(3):322–33.
11.
Albrektsson T, Isidor F. Consensus report
of Session IV.
→ In: Lang NP, Karring T, editors.
Proceedings of the first European
Workshop on Periodontology. London:
Quintessence.
1994. p. 365–9.
12.
Mombelli A, Müller N, Cionca N.
The epidemiology of peri-implantitis.
→ Clin Oral Implants Res.
2012 Oct;23 Suppl 6:67–76.
13.
Klinge B, Meyle J; Working Group 2.
Peri-implant tissue destruction. The
Third EAO Consensus Conference 2012.
→ Clin Oral Implants Res.
2012 Oct;23 Suppl 6:108–10.
14.
Quirynen M, Abarca M, Van Assche N,
Nevins M, van Steenberghe D. Impact of
supportive periodontal therapy and
implant surface roughness on implant
outcome in patients with a history of
periodontitis.
→ J Clin Periodontol.
2007 Sep;34(9):805–15.
20.
Pozzi A, Tallarico M, Moy PK. Three-year
post-loading results of a randomised,
controlled, split-mouth trial comparing
implants with different prosthetic
interfaces and design in partially posterior
edentulous mandibles.
→ Eur J Oral Implantol.
2014 Spring;7(1):47–61.
15.
Roccuzzo M, Bonino F, Aglietta M,
Dalmasso P. Ten-year results of a three
arms prospective cohort study on
implants in periodontally compromised
patients. Part 2: clinical results.
→ Clin Oral Implants Res.
2012 Apr;23(4):389–95.
21.
Isidor F. Influence of forces on
peri-implant bone.
→ Clin Oral Implants Res.
2006 Oct;17 Suppl 2:8–18.
16.
Manfredini D, Poggio CE, Lobbezoo F. Is
bruxism a risk factor for dental implants?
A systematic review of the literature.
→ Clin Implant Dent Relat Res.
2014 Jun;16(3):460–9.
17.
French D, Larjava H, Ofec R. Retrospective
cohort study of 4591 Straumann implants
in private practice setting, with up to
10-year follow-up. Part 1: multivariate
survival analysis.
→ Clin Oral Implants Res.
2015 Nov;26(11):1345–54.
18.
Mengel R, Flores-de-Jacoby L. Implants in
patients treated for generalized aggressive
and chronic periodontitis: a 3-year
prospective longitudinal study.
→ J Periodontol.
2005 Apr;76(4):534–43.
22.
Wennerberg A, Albrektsson T. On implant
surfaces: a review of current knowledge
and opinions.
→ Int J Oral Maxillofac Implants.
2010 Jan-Feb;25(1):63–74.
23.
Östman PO, Hellman M, Sennerby L.
Ten years later. Results from a prospective
single-centre clinical study on 121 oxidized
(TiUnite™) Brånemark implants in
46 patients.
→ Clin Implant Dent Relat Res.
2012 Dec;14(6):852–60.
24.
Albouy JP, Abrahamsson I, Persson LG,
Berglundh T. Spontaneous progression of
peri-implantitis at different types of
implants. An experimental study in dogs.
I: clinical and radiographic observations.
→ Clin Oral Implants Res.
2008 Oct;19(10):997–1002.
19.
Rosenberg ES, Cho SC, Elian N, Jalbout ZN,
Froum S, Evian CI. A comparison of
characteristics of implant failure and
survival in periodontally compromised and
periodontally healthy patients: a clinical
report.
→ Int J Oral Maxillofac Implants.
2004 Nov-Dec;19(6):873–9.
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 55
[56] =>
Flap design in periapical surgery
Flap design: New perspectives
in periapical surgery
Abstract
Maria Peñarrocha Diago,a Juan Cervera Ballestera
& David Peñarrocha Oltraa
a
Department of Stomatology, Faculty of Medicine and
Dentistry, University of Valencia, Valencia, Spain
Corresponding author:
Dr. María Peñarrocha Diago
Unidad de Cirugía Bucal. Clínicas Odontológicas
Facultad de Medicina y Odontología de Valencia
Universitat de València
Gascó Oliag, 1
46021 Valencia
Spain
Flap design in periapical surgery should be adequate for the planned
surgical procedure, offering good access to the zone surrounding the
affected apexes without altering the soft-tissue circulation. A fullthickness flap including mucosa, submucosal connective tissue and periosteum should be raised. A description is provided of the most frequently
used types of flaps in periapical surgery:
1. Luebke–Ochsenbein flap, involving submarginal incision,
with semilunar or Partsch flap variants;
2. Neumann flap with intrasulcular incision in its triangular
and trapezoidal versions;
maria.penarrocha@uv.es
3. papilla base incision flap;
How to cite this article:
4. papilla-preserving flap; and
Peñarrocha Diago M, Cervera Ballester J,
Peñarrocha Oltra D. Flap design: New perspectives
in periapical surgery.
J Oral Science Rehabilitation.
2017 Sep;3(3):56–61.
5. palatal flap.
Designing the flap is a key aspect of periapical surgery: It should ensure
adequate exposure of the surgical field and allow the surgeon to work
quickly and comfortably. Furthermore, there should be no tension capable
of complicating the work of the dental professional or of causing patient
discomfort, and soft-tissue damage due to retractor compression is to
be avoided. A good flap design with delicate manipulation of the soft
tissue is necessary for successful periapical surgery.
Keywords
Periapical surgery, endodontic surgery, surgical technique, flap design.
56 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[57] =>
Flap design in periapical surgery
Introduction
Types of flaps
Two factors are important for securing optimum
functional and esthetic outcomes in periapical
surgery: flap design and the suturing technique
used. Flap design in periapical surgery should
be adequate for the planned surgical procedure,
offering good access to the zone surrounding
the affected apexes without altering the circulation in either the mobilized or nonmobilized
soft tissue.1
A number of factors must be taken into
account in preparing the flap: the location and
extent of the apical lesion, the periodontal condition of the affected tooth and of the adjacent
teeth, the condition of the surrounding anatomical structures, and the presence and quality of
prosthetic restorations in contact with the gingival margin.1 The flap should encompass at least
one tooth on either side of the affected tooth.
Acute flap angles are to be avoided. A narrow
corner is difficult to trim and suture and can
suffer ischemia and become detached, favoring
the formation of scars.
A full-thickness flap including mucosa, submucosal connective tissue and periosteum
should be raised. The interdental papilla should
not be divided (sectioned) and should be either
totally included within or separate from the flap.
The incisions are to be sufficiently extensive to
ensure that the retractor rests on bone and does
not compress part of the flap.
Classically, the most commonly used type of flap
in periapical surgery has been the trapezoidal or
triangular Neumann flap, with an intrasulcular
incision and two vertical releasing incisions.
However, owing to the improvements in surgical
techniques and suture materials, oral surgery
has become more conservative and delicate, and
the Luebke–Ochsenbein flap with submarginal
incisions is now more widely used.
Fig. 1
1. Submarginal incision flap
(Luebke–Ochsenbein flap)
A horizontal incision is made in the attached
gingival tissue about 3–4 mm above the gingival
margin, with two vertical releasing incisions on
either side of the flap located one or two teeth
distal to where the lesion is located (Figs. 1–3).
This type of flap is easy to detach, but can leave
a postsurgical scar if the repositioning sutures
are not performed adequately.2
The Luebke–Ochsenbein flap is less aggressive with the gingival tissue than an intrasulcular incision flap, and it is easy to make the incision
slightly triangular or angled in order to secure
precise repositioning (Figs. 4–6). It is particularly useful in patients with fixed prosthesis
restorations, since correct application of the
technique results in less recession of the gingival margin3, 4 and interdental papillae.5
Fig. 2
Journal of
Oral Science & Rehabilitation
Fig. 3
Volume 3 | Issue 3/2017 57
Fig. 1
Clinical view before the
trapezoidal submarginal flap
for periapical surgery
of tooth #11.
Fig. 2
Detachment of the trapezoidal
submarginal flap.
Fig. 3
Intraoperative view after
ostectomy and resection of
the apex of tooth #11.
[58] =>
Flap design in periapical surgery
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 4
Initial view before preparation
of the triangular submarginal
flap for periapical surgery of
tooth #12.
Fig. 5
Detachment of the triangular
submarginal flap.
Fig. 6
Clinical view showing the
ostectomy for accessing the
apex of tooth #12.
Fig. 7
Clinical view of tooth #23
before surgery.
Fig. 8
Detachment of the semilunar
(Partsch) flap.
Fig. 9
Intraoperative view after
ostectomy to access the apex
of tooth #23.
The semilunar (Partsch) flap is a variant involving submarginal incision in the alveolar mucosa
to form a crescent- or semilunar-shaped flap. It
is little used in periapical surgery because it
affords limited surgical access to the root apex.
Furthermore, owing to the presence of muscle
fibers, flap tension is high, making suturing difficult and increasing the risk of suture dehiscence.6 The semilunar flap is almost exclusively
used in application to the maxillary canines
(Figs. 7–9).7 Care is required to avoid performing
the incision above the bone defect.
58 Volume 3 | Issue 3/2017
2. Neumann flap
with intrasulcular incision
This flap offers perfect access for periapical surgery, with sufficient access to the affected bone
and lesion-related roots.6 The intrasulcular incision in turn may be triangular or trapezoidal. The
most common intrasulcular flap involves a triangular incision with a single vertical releasing
incision located distal and one or two teeth distal
to the lesion. This flap is characterized by
increased tension, the traction forces increasing
Journal of
Oral Science & Rehabilitation
[59] =>
Flap design in periapical surgery
Fig. 11
Fig. 10
Fig. 10
Clinical view before periapical
surgery of tooth #21.
Fig. 11
Detachment of a triangular
flap with sulcular incision.
Fig. 12
Intraoperative view after
ostectomy.
Fig. 13
Clinical view before periapical
surgery of teeth #12 and 22.
Fig. 12
Fig. 13
Fig. 14
Sulcular incision along the
gingival margin of the teeth
and two vertical releasing
incisions distal to the canines.
Fig. 15
Detachment of the trapezoidal
sulcular flap.
Fig. 14
Fig. 15
especially at the fixed extremity (Figs. 10–12).
This technique allows easy flap repositioning
after periapical surgery.
A modification of this flap involves a trapezoidal incision where a horizontal incision is
made over the interdental papillae and along the
neck of the teeth. Furthermore, two vertical
releasing incisions are made on either side of the
flap (leaving one or two teeth outside the lesion
as a safety margin; Figs. 13–15). The important
inconvenience of this technique is that postoperative gingival recession can occur—with a
strong esthetic impact in the case of surgery of
the anterior maxillary segment.3, 5, 8
3. Flap with incision
at the base of the papillae
This flap was originally described by Velvart9
and is characterized by a horizontal incision following the dental sulcus along the neck of the
teeth and extending to the base of the papillae.
The latter is left adhered for posterior suturing
of the flap. A vertical releasing incision is more-
Journal of
Oral Science & Rehabilitation
Volume 3 | Issue 3/2017 59
[60] =>
Flap design in periapical surgery
Fig. 16
Fig. 18
Fig. 17
Fig. 19
Fig. 20
Fig. 16
Clinical view before periapical
surgery of tooth #11.
Fig. 17
Flap at the base of the
interdental papillae to ensure
their preservation.
Fig. 18
Clinical view before surgery
of tooth #34.
Fig. 19
Design and detachment of
a papilla-preserving flap.
Fig. 20
Intraoperative view after
ostectomy.
over made (Figs. 16 & 17). This is a surgically
5. Palatal flap
complicated flap requiring adequate surgeon
experience. The literature shows this technique A festoon flap is performed at the gingival marto produce less recession at interdental papillary gins on the palatal side. This flap is used in perilevel than a sulcular incision.8
apical surgery of the palatal roots of the maxillary molars. If the flap needs to be expanded to
4. Papillagain greater visibility, the incision can be
preserving incision flap
extended mesial to the canine. Palatal releasing
incisions are not necessary, though if any such
In this case, a horizontal incision is made following incision is made, it should be performed between
the dental sulcus to the dental papilla, avoiding the canine and premolar—which represents the
incision of the latter and tracing the vertical releas- vascularization limit between the nasopalatine
ing incision at this point.4 This flap is useful in teeth artery and the anterior palatine artery—or distal
with a generous mesiodistal width, affording an to the second molar, behind the emergence point
adequate surgical field (Figs. 18–20).
of the anterior palatine artery (Figs. 21–23).10
60 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[61] =>
Flap design in periapical surgery
Fig. 21
Fig. 22
Fig. 23
Conclusion
pression is to be avoided. A good flap design with
delicate manipulation of the soft tissue is necesDesigning the flap is a key aspect of periapical sary for successful periapical surgery.
surgery: It should ensure adequate exposure of the
surgical field and allow the surgeon to work quickly
and comfortably. Furthermore, there should be no
Competing interests
tension capable of complicating the work of the
dental professional or of causing patient discom- The authors declare that they have no competfort, and soft-tissue damage due to retractor com- ing interests.
Fig. 21
Clinical view before the
festoon palatal flap.
Fig. 22
Design and detachment
of a palatal flap.
Fig. 23
Ostectomy for accessing
the palatal root.
References
1.
Arens DE. Flap design.
→ In: Arens DE, editor. Practical lessons
in endodontic surgery.
Chicago: Quintessence; 1998. p. 51–64.
2.
Vreeland DL, Tidwell E. Flap design
for surgical endodontics.
→ Oral Surg Oral Med Oral Pathol.
1982 Oct;54(4):461–5.
3.
Von Arx T, Vinzens-Majaniemi T, Bürgin W,
Jensen SS. Changes of periodontal
parameters following apical surgery: a
prospective clinical study of three incision
techniques.
→ Int Endod J.
2007 Dec;40(12):959–69.
4.
Kreisler M, Gockel R, Schmidt I, Kühl S,
d’Hoedt B. Clinical evaluation of a
modified marginal sulcular incision
technique in endodontic surgery.
→ Oral Surg Oral Med Oral Pathol Oral
Radiol Endod.
2009 Dec;108(6):e22–8. doi:10.1016/j.
tripleo.2009.08.005.
5.
Von Arx T, Salvi GE, Janner S, Jensen SS.
Gingival recession following apical
surgery in the esthetic zone: a clinical
study with 70 cases.
→ Eur J Esthet Dent.
2009 Spring;4(1):28–45.
6.
Velvart P, Peters CI. Soft tissue
management in endodontic surgery.
→ J Endod.
2005 Jan;31(1):4–16.
7.
Peñarrocha M. Técnica quirúrgica.
→ In: Peñarrocha M, editor. Cirugía
periapical.
Barcelona: Ars Medica; 2004. p. 45–79.
8.
Velvart P, Ebner-Zimmermann U, Ebner JP.
Comparison of papilla healing following
sulcular full-thickness flap and papilla base
flap in endodontic surgery.
→ Int Endod J.
2003 Oct;36(10):653–9.
Journal of
Oral Science & Rehabilitation
9.
Velvart P. Papilla base incision: a new
approach to recession-free healing
of the interdental papilla after endodontic
surgery.
→ Int Endod J.
2002 May;35(5):453–60.
10.
Peñarrocha Oltra D, Cervera Ballester J,
Zubeldia Masset P, Luis Calvo Guirado J,
Peñarrocha Diago M. Técnica quirúrgica
básica.
→ In: Peñarrocha M, Peñarrocha MA,
editors. Atlas de cirugía periapical.
Madrid: Ergon; 2013. p. 47–97.
Volume 3 | Issue 3/2017 61
[62] =>
Meetings
Fourth MIS Global Conference
Paradise Island, Bahamas — February 2018
The next MIS Global Conference is to take place
from February 8 to 11 at the beautiful Atlantis
Resort in the Bahamas. After the tremendous
success of the last conference in Barcelona,
Spain, with its fascinating scientific program,
high-level lectures and amazing entertainment,
this global conference promises to deliver yet
another intense and unforgettable experience.
Inspiring speakers with a world of
experience
The scientific committee, headed by Prof. Lior
Shapira, has undertaken the challenge of making
this year’s conference even better than before.
Shapira and his colleagues are “making every
effort to address contemporary treatment possibilities, and provide insight into the present
and future of dental implants as part of clinical
dentistry.” They have also promised that “the
podium will be occupied by high-quality clinicians, researchers, and educators who will share
… their extraordinary experience and clinical
excellence.”
With the official launch of the V3 Implant
System in the U.S. currently underway, MIS is
devoted to bringing the dental world the latest
innovations and is committed to helping clinicians improve patient care. At the conference,
various workshops will provide opportunities
for meaningful learning in an intimate environment, with accomplished experts in specific
areas of interest. The two-day main program
will feature world-prominent speakers presenting their expertise, which could be implemented
in everyday dental practice and optimize dentists’ skills for the benefit of their patients. Some
of the key topics include evolution and horizons
in implant therapy, biological principles and predictable esthetics, the long-term forecast for
implant therapy and going digital.
62 Volume 3 | Issue 3/2017
TEDxMIS
In the spirit of “ideas worth spreading” and a
commitment to innovation, MIS is proud to
announce its partnership with TEDx. TEDxMIS
is an independently organized TED event that
will take place on February 10 and feature
world-leading thinkers and achievers in the field
of implant dentistry. The goal of TEDxMIS is to
give conference guests the opportunity to experience a unique series of fast-paced, eye-opening
talks that will inspire them and provoke meaningful engagement with their peers.
Call for clinical cases
As part of its commitment to promoting young
clinicians, MIS is continuing the tradition of holding a clinical case competition during the global
conference. For the 2018 event, the focus will
be on modern technologies and techniques in
clinical practice. The 15 best clinical cases will
be presented as posters at the conference venue,
with prizes awarded to the three winning cases.
Breathtaking views
and spectacular entertainment
Similar to past events, the 2018 conference is
expected to be an extraordinary experience of
knowledge sharing, with the opportunity to network with colleagues from the international
dental community. This year, however, conference guests will also enjoy one of the most beautiful and exotic locations in the Atlantic Ocean,
the Atlantis Resort on Paradise Island. When
they are not engaged in the workshops and lectures, guests will be able to take in the marine
habitat, participate in sports activities, and
explore the culture and colors of the Bahamas.
Full of impressive and fun events, the MIS Global
Conference entertainment program will leave
guests with fond memories and looking forward
to the next gathering.
Journal of
Oral Science & Rehabilitation
[63] =>
www.idem-singapore.com
13 -15 APRIL 2018
SUNTEC SINGAPORE
THE LEADING DENTAL EXHIBITION
AND CONFERENCE IN ASIA PACIFIC
SCIENTIFIC CONFERENCE
Our professional journey continues its sharp focus on the point of care and
service to the patient, bringing in speakers that represent leaders, role models
and mentors from every dental setting. Learn practical techniques based upon
widely accepted evidence from these experts to enhance your day-to-day
practice.
TRADE EXHIBITION
Meet over 550 exhibitors at IDEM and discover the latest products and services
the dental industry has to offer. IDEM attracts all the major players in the dental
industry to the Asia Pacific for three power packed days of exhibition, making it
the ideal platform to cement your existing professional relationships and
connect with future business partners.
ONLINE REGISTRATION NOW OPEN!
Registration
Koelnmesse Pte Ltd
Ms. Cindy Tantarica
T: +65 6500 6700
E: idem-reg@koelnmesse.com.sg
Connect with us
Endorsed by
Supported by
Held in
Organised by
IDEM Singapore
IDEM Singapore
idem.sg
Singapore Dental Association
[64] =>
Guidelines for authors
Authors must adhere
to the following guidelines
Informed consent
It is preferred that there be no more than six authors.
If more authors have participated in the study, the
Patients have a right to privacy that should not be violated without informed consent. contribution of each author must be disclosed at the
Identifying information, including patients’ names, initials or hospital numbers, should end of the document.
not be provided in the manuscript or visual material unless the information is essential
Title
for scientific purposes and the patient (or parent or guardian) has given written informed
consent for publication. Informed consent for this purpose requires that an identifiable
patient be shown the manuscript to be published. Authors should disclose to these The title should not exceed 35 characters. Capitalize
patients whether any potential identifiable material might be available via the Internet only the first word and proper nouns in the title. Please
as well as in print after publication. Nonessential identifying details should be omitted. include a running title as well.
Informed consent should be obtained if there is any doubt that anonymity can be mainAuthor information
tained. For example, masking the eye region in photographs of patients is inadequate
protection of anonymity. If identifying characteristics are altered to protect anonymity,
authors should provide assurance that alterations do not distort scientific meaning. The following information must be included for each
When informed consent has been obtained, it should be indicated in the manuscript. author:
– Full author name(s)
– Full affiliation (department, faculty, institution,
town, country).
Human and animal rights
When reporting experiments on human subjects, authors should indicate whether the
procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1975, as revised in 2013 (www.wma.net/en/30publications/ 10policies/b3/index.html). If doubt exists whether the research was conducted in accordance
with the Declaration of Helsinki, the authors must explain the rationale for their approach, and demonstrate that the institutional review body explicitly approved the
doubtful aspects of the study. When reporting experiments on animals, authors should
indicate whether institutional and national standards for the care and use of laboratory
animals were followed. Further guidance on animal research ethics is available from the
International Association of Veterinary Editors’ Consensus Author Guidelines on Animal
Ethics and Welfare (www.veteditors.org/consensus-author-guidelines-onanimalethics-and-welfare-for-editors).
For the corresponding author, the following information should be included in addition:
– Full mailing address
– Email address.
Abstract and keywords
The manuscript must contain an abstract and a minimum of 3, maximum of 6 keywords. The abstract
should be self-contained, not cite any other work and
not exceed 250 words. It should be structured into the
following separate sections: objective, materials and
methods, results, conclusion and keywords. For case
reports, the sections should be background, case
presentation, conclusion and keywords.
Structure of the main text
Preparing the manuscript text
The body of the manuscript must be structured
as follows:
– Introduction (no subheadings)
– Materials and methods
– Results
The manuscript must be written in U.S. English. The – Discussion
main body of the text, excluding the title page, ab- – Conclusion.
stract and list of captions, but including the references, may be a maximum of 4,000 words. ExcepCompeting interests
tions may be allowed with prior approval from the
publisher.
Authors are required to declare any competing financial
or other interests regarding the article submitted. Such
Authors will have the opportunity to add more infor- competing interests are to be stated at the end of manmation regarding their article, as well as post videos, uscript before the references. If no competing interests
present a webinar and blog on the DT Science web- are declared, the following will be stated: “The authors
site.
declare that they have no competing interests.”
General
64 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
[65] =>
Guidelines for authors
gether, then use lowercase letters to designate these
in a group (e.g., “Figs. 2a–c”).
Acknowledgments
Acknowledgments (if any) should be brief and included at the end of the manuscript before the refer- Place the references to the images in your article
wherever they are appropriate, whether in the midences, and may include supporting grants.
dle or at the end of a sentence. Provide a caption for
each image at the end of your article.
References
Authors are responsible for ensuring that the information for each reference is complete and accurate.
All references must be cited within the manuscript.
References appearing in the list but not in the manuscript will be removed. In-text citation should follow
the citation–sequence format (e.g., “as discussed by
Haywood et al.15”) using superscript numbers placed
after the punctuation in the relevant sentence. The
references must be numbered consecutively.
Requirements for tables
Each table should be supplied separately and in Microsoft Word format. Tables may not be embedded as
images and no shading or color is to be used.
Tables should be cited consecutively in the manuscript. Place the references to the tables in your article
wherever they are appropriate, whether in the middle
or at the end of a sentence. Every table must have a
The reference list must be numbered and the refer- descriptive caption, and if numerical measurements
ences provided in order of appearance. For the refer- are given the units should be included in the column
ence list, the journal follows the citation style stipu- headings.
lated in Citing medicine: the NLM style guide for auSupplements/supporting material
thors, editors, and publishers. The guidelines may be
viewed and downloaded free of charge at
DT Science allows an unlimited amount of supporting material (such as datasets, videos or other addiwww.ncbi.nlm.nih.gov/books/NBK7256/
tional information) to be uploaded. This material
The reference list may not exceed 50 references.
should be presented succinctly (in English). The author bears full responsibility for the content. Color,
List of captions
animated multimedia presentations, videos and so
Please provide the captions for all visual material at on are welcome and published at no additional cost
to the author or reader. Please refer briefly to such
the end of the manuscript.
material in the manuscript where appropriate (e.g.,
as an endnote).
Abbreviations
Abbreviations should be used sparingly and defined
when first used. The abstract and the main manuscript text should be regarded as separate documents
in this regard.
Typography
– Use Times New Roman regular with a font size of 12 pt.
– Use double line spacing with blank lines separating sections and paragraphs.
– Type the text unjustified and do not apply
hyphenation at line breaks.
– Number all of the pages.
– Use endnotes if necessary, but not footnotes.
– Greek and other special characters may be
included.
Submit your research and
clinical articles to
Dr. Daniele Botticelli at
daniele.botticelli@gmail.com
For all other requests,
contact
Preparing the visual material
Requirements for images
Each image should be supplied separately and the
following formats are accepted: PSD, TIFF, GIF and
JPEG. The image must have a resolution of 300 dpi
and must be no smaller than 6 cm × 6 cm.
Please number the images consecutively throughout
the article by using a new number for each image. If
it is imperative that certain images be grouped to-
Journal of
Oral Science & Rehabilitation
Nathalie Schüller at
n.schueller@dental-tribune.com
T +49 341 4847 4136
Dental Tribune International Publishing Group
Holbeinstr. 29
04229 Leipzig
Germany
www.dtscience.com
www.dental-tribune.com
Volume 3 | Issue 3/2017
65
[66] =>
Imprint: About the publisher
Publishing team
Editorial board
Publisher/President/CEO
Editor-in-Chief
Torsten R. Oemus
t.oemus@dental-tribune.com
Ugo Covani, Pisa and Camaiore, Italy
Co-editors
Managing Editor
International office
Dental Tribune International
Holbeinstr. 29
04229 Leipzig
Germany
T +49 341 4847 4302
F +49 341 4847 4173
info@dental-tribune.com
www.dental-tribune.com
Nathalie Schüller
n.schueller@dental-tribune.com
Daniele Botticelli, Rimini, Italy
José Luis Calvo Guirado, Murcia, Spain
Miguel Peñarrocha Diago, Valencia, Spain
Concept & design
Associate editors
Rhowerk
www.rhowerk.de
Antonio Barone, Geneva, Switzerland
Luigi Canullo, Rome, Italy
Rafael Arcesio Delgado Ruiz, Stony Brook, N.Y., U.S.
David Peñarrocha Oltra, Valencia, Spain
C h i e f Te c h n o l o g y O f f i c e r
Serban Veres
serbanveres@gmail.com
Copy editor
Scientific advisers
Pablo Galindo Moreno, Granada, Spain
Georgios Romanos, Stony Brook, N.Y., U.S.
Giovanni Serino, Borås, Sweden
Sabrina Raaff
Ann-Katrin Paulick
Statistical advisers
International administration
Marco Tallarico, Sassari, Italy
Francesco Tessarolo, Mattarello, Italy
Chief Financial Officer
Dan Wunderlich
d.wunderlich@dental-tribune.com
Marketing & Sales Services
Nadine Dehmel
n.dehmel@dental-tribune.com
Nicole Andrä
n.andrae@dental-tribune.com
Accounting Services
Karen Hamatschek
k.hamatschek@dental-tribune.com
Manuela Hunger
m.hunger@dental-tribune.com
Anja Maywald
a.maywald@dental-tribune.com
Executive Producer
Gernot Meyer
g.meyer@dental-tribune.com
Copyright regulations
The Journal of Oral Science & Rehabilitation is published quarterly by Dental Tribune International (DTI).
The journal and all articles and illustrations contained therein are protected by copyright. Any utilization
without the prior consent of the authors, editor and publisher is prohibited and liable to prosecution.
This applies in particular to the duplication of copies, translations, microfilms, and storage and processing
in electronic systems. Reproductions, including extracts, may only be made with the permission of the
publisher. Given no statement to the contrary, any submissions to the editorial department are understood
to be in agreement with full or partial publishing of said submission. The editorial department reserves
the right to check all submitted articles for formal errors and factual authority, and to make amendments
if necessary. Articles bearing symbols other than that of the editorial department, or that are distinguished
by the name of the author, represent the opinion of the afore-mentioned, and do not have to comply
with the views of DTI. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise,
no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are
excluded. The legal domicile is Leipzig, Germany.
Printer
Löhnert Druck | Handelsstr. 12 | 04420 Markranstädt | Germany
66 Volume 3 | Issue 3/2017
Journal of
Oral Science & Rehabilitation
Executive board
Daniele Botticelli, Rimini, Italy
Luigi Canullo, Rome, Italy
Torsten R. Oemus, Leipzig, Germany
Board of reviewers
Marcus Abboud, Stony Brook, N.Y., U.S.
Marco Álvarez, Mexico City, Mexico
Conrado Aparicio, Minneapolis, Minn., U.S.
Shunsuke Baba, Osaka, Japan
Franco Bengazi, Brescia, Italy
Andrea Edoardo Bianchi, Milan, Italy
Manuel Bravo Pérez, Granada, Spain
Eriberto Bressan, Padua, Italy
Marco Caneva, Trieste, Italy
Juan Carlos De Vicente Rodríguez, Oviedo, Spain
Stefan Fickl, Würzburg, Germany
Joseph Fiorellini, Philadelphia, Pa., U.S.
Abel García García, Santiago de Compostela, Spain
Gerardo Gómez Moreno, Granada, Spain
Federico Hernández Alfaro, Barcelona, Spain
Carlos Larrucea Verdugo, Talca, Chile
Baek-Soo Lee, Seoul, South Korea
Dehua Li, Xi’an, China
Francesco Guido Mangano, Milan, Italy
Aleksa Markovic, Belgrade, Serbia
José Eduardo Maté Sánchez de Val, Murcia, Spain
Silvio Meloni, Sassari, Italy
Eitan Mijiritsky, Tel Aviv, Israel
Alberto Monje, Ann Arbor, Mich., U.S.
Yasushi Nakajima, Osaka, Japan
Ulf Nannmark, Gothenburg, Sweden
Wilson Roberto Poi, Araçatuba, Brazil
Rosario Prisco, Foggia, Italy
Alessandro Quaranta, Dunedin, New Zealand
Maria Piedad Ramírez Fernández, Murcia, Spain
Idelmo Rangel García, Araçatuba, Brazil
Fabio Rossi, Bologna, Italy
Hector Sarmiento, Philadelphia, Pa., U.S.
Nikola Saulacic, Bern, Switzerland
Alessandro Scala, Pesaro, Italy
Carlos Alberto Serrano Méndez, Bogotá, Colombia
Andrew Tawse-Smith, Dunedin, New Zealand
Cemal Ucer, Manchester, U.K.
Joaquín Urbizo Velez, La Habana, Cuba
[67] =>
17071401
Top DM
DM Implant system
Bioetch
Surface
TOP DM
®
The best Titanium
grade 5 implant surface
Bioetch® , the exclusive surface developed by Bioner for its implant
Top DM, is the result of a double
acid etching process that provides
the implant with a micro and macro
structured surface. This particular
surface morphology enhances
osseintegration. It is obtained
without sandblasting prior to the
acid attack, thus eliminating the
risk of surface contamination . With
an average roughness value of 1,3
microns, Top DM has the best Titanium grade 5 surface available in
the market.
www.bioner.es
)065,9:(,ZWPNVSLYH
:HU[1\Z[+LZ]LYU)HYJLSVUH
+34 934 700 360
bioner@bioner.es
Follow us:
[68] =>
A prosthesis on an
implant as beautiful
as a natural tooth.
It is possible.
Dr. Ignazio Loi
Prama, the transgingival implant
conceived according to the principles
of the B.O.P.T. technique,
reveals its versatility also simplifying
full arch rehabilitations.
The freedom of choice between a
cylindrical or conical endosseous
morphology makes surgically
positioning it simple and secure.
The wide range of prosthetic solutions
covers all clinical needs,
from a single crown in esthetic
sectors to overdentures.
Prama is the implant to reach
prosthetic excellence, always.
sweden-martina.com
)
[page_count] => 68
[pdf_ping_data] => Array
(
[page_count] => 68
[format] => PDF
[width] => 595
[height] => 842
[colorspace] => COLORSPACE_UNDEFINED
)
[linked_companies] => Array
(
[ids] => Array
(
)
)
[cover_url] =>
[cover_three] =>
[cover] => ![Journal of Oral Science & Rehabilitation No. 3, 2017]()
[toc] => Array
(
[0] => Array
(
[title] => Editorial
[page] => 03
)
[1] => Array
(
[title] => About the Journal of Oral Science & Rehabilitation
[page] => 06
)
[2] => Array
(
[title] => Accuracy of computer-assisted template-based implant placement using a conventional impression and scan model or digital impression: A prelimi- nary report from a randomized controlled trial
[page] => 08
)
[3] => Array
(
[title] => Zero apicectomy in endodontic microsurgery
[page] => 18
)
[4] => Array
(
[title] => How can the tapered implant design influence bundle bone preservation: An experimental study in American Foxhound dogs
[page] => 28
)
[5] => Array
(
[title] => Improved fully digital workflow to rehabilitate an edentulous patient with an implant overdenture in 4 appointments: A case report
[page] => 38
)
[6] => Array
(
[title] => Thirteen-year follow-up of a cross-arch implant-supported fixed restoration in a patient with generalized aggressive periodontitis and parafunctional habits
[page] => 48
)
[7] => Array
(
[title] => Flap design: New perspectives in periapical surgery
[page] => 56
)
[8] => Array
(
[title] => Fourth MIS Global Conference
[page] => 62
)
[9] => Array
(
[title] => Guidelines for authors
[page] => 64
)
[10] => Array
(
[title] => Imprint — about the publisher
[page] => 66
)
)
[toc_html] =>
[toc_titles] => Editorial
/ About the Journal of Oral Science & Rehabilitation
/ Accuracy of computer-assisted template-based implant placement using a conventional impression and scan model or digital impression: A prelimi- nary report from a randomized controlled trial
/ Zero apicectomy in endodontic microsurgery
/ How can the tapered implant design influence bundle bone preservation: An experimental study in American Foxhound dogs
/ Improved fully digital workflow to rehabilitate an edentulous patient with an implant overdenture in 4 appointments: A case report
/ Thirteen-year follow-up of a cross-arch implant-supported fixed restoration in a patient with generalized aggressive periodontitis and parafunctional habits
/ Flap design: New perspectives in periapical surgery
/ Fourth MIS Global Conference
/ Guidelines for authors
/ Imprint — about the publisher
[cached] => true
)
