Journal of Oral Science & Rehabilitation No. 4, 2018Journal of Oral Science & Rehabilitation No. 4, 2018Journal of Oral Science & Rehabilitation No. 4, 2018

Journal of Oral Science & Rehabilitation No. 4, 2018

Cover / Editorial / Content / About the Journal of Oral Science & Rehabilitation / Guided soft-tissue emergence profile techniques using CAD/CAM technologies: Multiple case reports / Implant-supported fixed full-arch rehabilitation without bone grafting in severely atrophic maxillae: A 10- to 12-year retro spective follow-up study / A minimally invasive technique for transcrestal sinus floor elevation / The relationship between oral squamous cell carcinoma and dental implants: A literature review / The effect of autoclavable polytetrafluoroethylene strips as adjuvant to hemostatic material in periapical surgery: A technical note / Unlikely case of submasseteric abscess originating from a maxillary molar: The skipping lesion / Authors must adhere to the following guidelines / Imprint

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Journal of

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

Volume 4 — Issue 4/2018

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

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


[2] =>
Dental Tribune International

ESSENTIAL
DENTAL MEDIA
www.dental-tribune.com


[3] =>
Editorial

Journal of

Oral Science
&
Rehabilitation
Apical periimplantitis: Diagnosis and treatment

Apical periimplantitis—also known as periapical implant lesions—develops in the tissues around the
apex of an implant after placement, while the bone architecture in the coronal portion is maintained.
If left untreated, this pathology eventually causes osseointegration failure. The diagnosis of apical
periimplantitis is based on the clinical and radiographic findings. Clinically, early apical periimplantitis
is characterized by symptoms (pain and tightness) and signs (swelling, fistula and drainage) of variable
intensity, depending on the stage of the lesion. Clinically, the patient complains of pain and inflammation
appearing, although in the early phase, there may be pain but not inflammation. Radiographically, a
radiolucency around the implant apex may be observed (although it is not necessary—the same happens
in acute periapical periodontitis, which may have symptoms without radiographic alterations). The
use of new imaging technologies such as small-volume cone beam computed tomography is helpful
in establishing an early diagnosis, showing a clear clinical image of periapical implant bone loss.
In the literature, there are few papers on diagnosing this disease and these lack homogeneity of
diagnosis criteria. Diagnosis of apical periimplantitis involves clinical and radiographic evaluation,
and the treatment will vary according to the findings:
a) If the implant has a radiolucent area (not present after surgery owing to overdrilling and manifesting
over time) without pain, monitoring of the lesion is recommended, without medical treatment.
b) If the radiolucency has increased in size or if the patient develops pain, medical and surgical treatment
are indicated.
Early diagnosis and management of active apical periimplantitis lesions (nonsuppurative phase with
symptoms, acute suppurative and subacute phases) includes the surgical approach and its follow-up
to evaluate the success of the treatment and avoid implant failure.
The literature describes medical and surgical approaches to treating periapical implant lesions. Medical
treatment using antibiotics (amoxicillin, amoxicillin/clavulanate, metronidazole and clindamycin)
alone has proved ineffective in controlling symptomatic or active lesions, and surgical access must
be performed. There is no established gold standard treatment, so the goal is to eliminate the area
of infection. Surgical treatment entails anesthesia, incision, full-thickness flap elevation, ostectomy,
apical curettage and abundant irrigation. After debridement, some authors have described irrigation
of the bone defect with saline solution or with chlorhexidine. Other agents have been suggested for
local decontamination of the implant surface, such as chlorhexidine, calcium hydroxide paste and
tetracycline pastes. There is no clinical evidence on the efficacy of any of these agents. Some studies
describe the use of biomaterials, with or without membranes, in order to achieve complete bone
regeneration of the defect. Resection of the apex of the implant is recommended in those cases where
access for removal of the granular tissue is not otherwise ensured, likewise when there is an anatomical
relationship with the maxillary sinus or nasal cavity.
Dr. Miguel Peñarrocha Diago
Editor-in-Chief

Journal of
Oral Science & Rehabilitation

Volume 4 | Issue 4/2018 03


[4] =>
Content

3
Editorial
Dr. Miguel Peñarrocha Diago
6
About the Journal of Oral Science & Rehabilitation
8
Christian Brenes & Wally Renne
Guided soft-tissue emergence profile techniques using CAD/CAM
technologies: Multiple case reports
18
Javier Aizcorbe Vicente et al.
Implant-supported fixed full-arch rehabilitation without bone grafting in
severely atrophic maxillae: A 10- to 12-year retrospective follow-up study
26
Leonardo Trombelli et al.
A minimally invasive technique for transcrestal sinus floor elevation
36
Ángela Rodríguez Caballero et al.
The relationship between oral squamous cell carcinoma and dental
implants: A literature review
46
Guillermo Cabanes Gumbau et al.
The effect of autoclavable polytetrafluoroethylene strips as adjuvant
to hemostatic material in periapical surgery: A technical note
52
Min Jim Lim & Alauddin Muhamad Husin
Unlikely case of submasseteric abscess originating from maxillary molar:
The skipping lesion
56
Guidelines for authors
58
Imprint — about the publisher

04 Volume 4 | Issue 4/2018

Journal of
Oral Science & Rehabilitation


[5] =>
Stay original. Trust in 10+ years of clinical experience.

NobelActive®
10+ years of clinical experience
41 clinical studies
98.5 % mean implant survival rate*
2,600+ patients evaluated
14,300+ implants clinically studied

* Up to 5 years of follow-up
Nobel Biocare. NobelActive® Over 10 years of clinical experience. Science First 2018, Volume 5, Issue 1.
GMT 58360 GB 1809 © Nobel Biocare Services AG, 2018. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a
certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/trademarks for more information. Product images are not necessarily to scale. Disclaimer: Some products may not be regulatory
ENGCTGFTGNGCUGFHQTUCNGKPCNNOCTMGVU2NGCUGEQPVCEVVJGNQECN0QDGN$KQECTGUCNGUQHƂEGHQTEWTTGPVRTQFWEVCUUQTVOGPVCPFCXCKNCDKNKV[(QTRTGUETKRVKQPWUGQPN[%CWVKQP(GFGTCN 7PKVGF5VCVGU NCYTGUVTKEVU
this device to sale by or on the order of a licensed dentist. See Instructions for Use for full prescribing information, including indications, contraindications, warnings and precautions.


[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 4 | Issue 4/2018

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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
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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.

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G u i d e d s o f t - t i s s u e c o n t o u r i n g u s i n g C A D/C A M

Guided soft-tissue emergence
profile techniques using
CAD/CAM technologies:
Multiple case reports

Abstract
Objective
Christian Brenesa & Wally Renneb
a

Department of General Dentistry, Dental College of
Georgia, Augusta University, Augusta, Ga., U.S.
b
Medical University of South Carolina, Charleston,
S.C., U.S.

Corresponding author:
Dr. Christian Brenes
Department of General Dentistry
Dental College of Georgia
Augusta University
1120 15th St.
GC-3224
Augusta, Ga. 30912
United States
cbrenesvega@augusta.edu

The following article describes 2 original techniques that use CAD/CAM
technology to generate a pre-surgical healing abutment or provisional
restoration.
Materials and methods

Two clinical cases are described using different techniques to create a
guided soft-tissue emergence profile using a pre-surgical custom healing abutment or provisional restoration and their benefits. The first case
describes the use of digital libraries with pontic emergence profiles. The
3-D object (tooth) is manipulated to replicate or to establish a natural
contour that will determine the shape of the soft tissue during the healing process. The second technique describes the use of segmentation
and mirroring of a natural tooth to generate an exact replica and emergence profile of the patient’s dentition.

How to cite this article:
Brenes C, Renne W. Guided soft-tissue emergence
profile techniques using CAD/CAM technologies:
Multiple case reports.
J Oral Science Rehabilitation. 2018 Dec;4(4):08–16.

Conclusion

These techniques constitute a very simple and efficient way of generating a pre-surgical customized healing abutment or provisional restoration
that allows the clinician to guide the soft-tissue healing process and
emergence profile immediately after the surgery. The techniques are
developed not to be software-specific, but rather to be used with any
free or paid open architecture software.
Keywords

CAD/CAM; guided surgery; 3-D printing; segmentation; digital wax-up.
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Introduction
Since 1989, Smith and Zarb incorporated
appearance into the criteria for dental implant
success.1 Decades of evidence supports the
importance of generating implant-supported
esthetic restorations, with little attention to
improving the soft-tissue emergence profiles or
natural contours of the teeth.2 Immediate provisional restorations are generally a good way
to manage soft-tissue contours, aiding during
the healing process with obvious esthetic benefits. Several authors have reported great
results during decades of using traditional provisional techniques by minimally altering the
biology of the soft tissue during the healing
process.3 The main limitation of traditional techniques is the chair time needed during or after
the surgical procedure to fabricate such provisional restorations; when determining the efficiency of a protocol, the time factor is critical
and most clinicians choose standard cylindrical
abutments to guide tissue contours before the
final impression. Abrahamsson et al. reported
that subsequent disconnections and reconnections of abutment components might compromise the mucosal barrier, and this could lead to
retraction or apically positioned connective
tissue due to increased bone remodeling. 4 In
addition, most cylindrical and unnatural emergence profiles could lead to food impaction and
possible biological complications due to poor
emergence profiles, food impaction and potential periimplantitis.
In the past, several authors described accelerated dental implant protocols such as immediate placement and immediate provisionalization. 2 , 5 Recently, some companies have
developed anatomical healing abutments that,
in contrast to custom healing abutments, have
an anatomical shape based on average standardized healing profiles. Systems such as Contour
Healer (Common Sense Dental Products), which
are anatomical PEEK abutments that can be
shaped, and the VPI EPI mold system (VP Innovato Holdings), which helps fabricate composite
anatomical abutments from a silicone mold, are
among the most popular systems. The limitations of using such analogue systems are reliance on the limited implant brands they are
compatible with, the healing process not being
guided from the emergence profiles of the final
restoration or wax-up, and being able to fabricate healing abutments only, but not provisional
crowns (Figs. 1 & 2A & B).

The use of CAD/CAM technologies has offered
different techniques to generate custom restorations. Most systems allow for the scanning of
scan bodies after implant placement to generate
an implant-supported provisional restoration, but
this technique only allows the clinician to generate the provisional restoration after the surgery.
The use of guided surgery in combination with
pre-surgical customized healing abutments or
provisional restorations with natural emergence
profiles can provide the clinician with a very
cost-effective and predictable way of replicating
nature and minimizing soft-tissue trauma.
Two different techniques are described for
the creation of a pre-surgical custom healing
abutment or provisional restoration. The first
case describes the use of digital libraries with
pontic emergence profiles. The 3 -D object
(tooth) is manipulated to replicate or to establish a natural contour of a tooth. The second
technique describes the use of segmentation
and mirroring of a natural tooth to generate an
exact replica and emergence profile of the
patient’s dentition.

Clinical case 1
A 52-year-old man presented to the Dental
College of Georgia at Augusta University,
Augusta, Georgia, U.S., with the chief complaint
of 2 missing posterior teeth (Fig. 3). During the
first appointment, clinical and radiographic
examinations were completed for proper diagnosis and formulation of treatment plan. The
periodontal condition was stable, no endodontic
lesions were found, and the patient reported
good hygiene. After proper diagnosis, it was
determined that the patient could be a candidate
for dental implant therapy. Digital impressions
were taken using the Medit i 500 intraoral
scanner (Medit), along with a CBCT scan. With
the diagnostic information acquired, the data
were imported into the free implant planning
software used in this case (Blue Sky Plan, Blue
Sky Bio) and the STL model aligned to the DICOM
volume using match points (Fig. 4).
The following steps describe the technique
of using digital libraries for a pre-surgical custom
healing abutment or provisional restoration:
1. A 3-D wax-up is fabricated in the implant
planning software. In this case, the Brenes
pontic library was used to recreate the
natural emergence profile of the restorations
(Figs. 5A & B).

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Fig. 1

Fig. 2A

Fig. 2B

Fig. 1
Contour Healer PEEK
abutment.
Figs. 2A & B
VPI EPI system.
Fig. 3
Intraoral occlusal view of
missing teeth #36 and 46.
Fig. 4
STL model aligned to DICOM
3-D reconstruction.

Fig. 3

Fig. 4

Fig. 5A

Fig. 5B

Fig. 5A
Digital wax-up using Brenes
pontic library of tooth #35
owing to lack of mesiodistal
space to replace tooth #36.
Fig. 5B
Digital wax-up using Brenes
pontic library of tooth #46 to
recreate the desired natural
emergence profile.

2. Proper implant planning and positioning
is done. In this case, 2 NobelReplace Con-

or printed and used as a scaffold for a composite healing abutment (Figs. 11A & B, 12).

ical Connection implants (Nobel Biocare)
were planned with their corresponding
digital temporary abutments to visualize
the final position of the screw access holes
(Figs. 6A–C).
3. The digital wax-up and temporary abutments are exported from the open architecture software (Blue Sky Plan) in STL format
and the files imported into Meshmixer
(Autodesk) or any software that allows for
3-D data manipulation (Fig. 7).
4. A cylinder that has the same width of the
temporary abutment is generated and positioned according the position of the restoration (Fig. 8).
5. The crown and the cylinder are selected and
a Boolean difference function is performed
to subtract the cylindrical shape from the
crown (Figs. 9A & B).
6. Alternatively, the provisional restoration is
cut using the plane cut function to generate
a healing abutment or a provisional restoration with flat anatomy that is not going to
be in occlusion (Fig. 10).
7. The new restoration, with an occlusal access
hole, is exported as an STL binary file to be
manufactured.
8. The restoration can be manufactured by
means of milling technologies using PMMA,
can be printed with biocompatible materials,

Two surgical guides ( 1 for each side) were
exported from Blue Sky Plan software and
printed using the Asiga MAX printer (Asiga) and
NextDent SG resin (NextDent; Fig. 13). The
pre-surgical custom healing abutments were
printed using NextDent C&B MFH resin and
attached with premise flowable composite (Kerr
Dental) to the temporary nonengaging abutments. The remaining metal structure of the
temporary abutments was cut with a diamond
disc and polished (Figs. 14A & B).
Two horizontal incisions were made over the
edentulous ridges after a proper anesthetic
effect was achieved; no vertical incisions were
required for a flapless approach. The surgical
guide was used to create 2 guided osteotomies
using a set of guided stoppers (Digital Dentistry
Education) in conjunction with Densah drills
(Versah) to place 2 4. 3 × 11 . 5 mm implants
(NobelReplace Conical Connection) in positions
#36 and 46. Excellent primary stability was
achieved and the 2 pre-surgical custom healing
abutments screwed in place (Fig. 15).
Three months later, the custom healing abutments were removed for the final impression,
the natural emergence profile of the tissue was
created and the tissue was healthy (Fig. 16). An
intraoral digital impression was taken to capture
the natural emergence profile of the soft tissue

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Fig. 6A

Fig. 6B

Fig. 6C

Fig. 7

Fig. 6A
Implant planning of 2 implants
(NobelReplace Conical
Connection) in positions #36
and 46.
Figs. 6B & C
Proper implant planning
with corresponding digital
temporary abutments.
Fig. 8

Fig. 9A

Fig. 7
Teeth with temporary
abutments to visualize the
final position of the screw
access holes.

Fig. 9B

Fig. 8
Tooth with generated cylinder
in Meshmixer.
Fig. 9A
Hole created on tooth after
Boolean difference operation.
Fig. 9B
Visualization of temporary
abutment through the hole.

Fig. 10

Fig. 11A

Fig. 10
Healing abutment created
after cutting the tooth
with the plane cut function
in Meshmixer.

Fig. 11B

Fig. 11A
Occlusal view of printed
healing abutments seated
on the nonengaging
temporary abutments.
Fig. 11B
Lateral view of printed healing
abutments seated on
the nonengaging temporary
abutments and their emergence profiles.
Fig. 12

Fig. 13

Fig. 14A

Fig. 14B

Fig. 12
Alternative copy of printed
pre-surgical custom healing
abutment using putty and
flowable composite to copy
the emergence profile.
Fig. 13
Printed surgical guide with
metal cylinder.
Fig. 14A
Pre-surgical healing abutment
for tooth #46.

Fig. 15

Fig. 16

Fig. 14B
Pre-surgical healing abutment
for tooth #36 with a
premolar shape owing to lack
of restorative space.
Fig. 15
Intraoral occlusal view of
pre-surgical healing
abutments immediately after
surgical procedure.
Fig. 16
Intraoral occlusal view of
the natural emergence
profiles of the tissue 3 months
post-surgery.

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Fig. 17A

Fig. 17B

Fig. 17C

Fig. 17D

Figs. 17A & B
Lateral view of final
restorations and Ti-bases.
Figs. 17C & D
Frontal view of final
restorations cemented on
Ti-bases.
Fig. 18
Intraoral occlusal view of final
screw-retained restorations.
Fig. 18

Fig.19A

Fig. 19B

Figs. 19A & B
Lateral view of final screwretained restorations.

using the Medit i 500 and Nobel-compatible
intraoral DESS scan bodies (DESS). Two
screw-retained crowns were designed using
Exocad (Exocad) over 2 DESS Ti-bases and
cemented with Maxcem Elite Chroma resin
cement (Kerr Corporation; Figs. 17A–D).
At the delivery appointment, the final
restorations were torqued following the
manufacturer’s recommendation, and the
access screw channel was covered with PTFE
tape and composite resin. The occlusion was
checked and the patient was satisfied with the
treatment outcome (Figs. 18, 19A & B).

Clinical case 2
A 56-year-old patient presented to the Medical
University of South Carolina with the chief complaint of a missing anterior tooth (Fig. 20). After
a thorough, but unremarkable health history and
clinical examination, an intraoral digital impression was taken (Planmeca Emerald, Planmeca)
at the consultation appointment and an ultralowdose CBCT scan (Planmeca ProMax 3D Max)
was also taken (Fig. 21). A mirror of the patient’s
tooth #9 was waxed into site #8 using the mirror
contralateral tooth feature in Planmeca Romexis
Version 5.2 (Planmeca; Fig. 22). The intraoral
scan and wax-up were merged with the CBCT
scan and an Astra Tech OsseoSpeed EV implant
(Dentsply Sirona) was planned, the adjacent root
segmented and a surgical guide created. All elements were exported into Meshmixer, and the
12 Volume 4 | Issue 4/2018

adjacent root was mirrored and then merged
with the original wax-up of tooth #11. Boolean
difference was then used to cut a perfect hole
in the digital design. The restoration was then
imported into the Planmill 30S (Planmeca) and
milled out of a resin nanoceramic material (Lava
U, 3M). Custom resin stains were used (Light
Art, Bisco).
The guided soft-tissue emergence profile
techniques using the segmentation approach
can be done using the following steps:
1. A digital wax-up is produced on the basis of an
intraoral digital impression. The digital wax-up
in the edentulous space is made using an exact
mirror image of the contralateral tooth in
Planmeca Romexis Version 5.2 (Fig. 22).
2. The intraoral digital impression and the
wax-up are merged with the CBCT scan using
common data points and then a best-fit algorithm is utilized to merge the 2 data sets
(Fig. 23). Proper digital planning and implant
placement are performed. In this case, the
implant was placed 3 mm apical to the
cementoenamel junction of the wax-up and
2 mm palatal (Fig. 24). The corresponding
manufacturer’s temporary abutment was
designed in the Planmeca Romexis abutment
editor and attached to the digital plan (Fig. 25).
3. The surgical guide is exported and then manufactured (Fig. 26).
4. The contralateral tooth and root were then
isolated and segmented using a fairly automated tooth segmentation feature in
Planmeca Romexis (Fig. 27).

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Fig. 21

Fig. 20

Fig. 20
Patient preoperative condition.
Fig. 21
Image captured from
Planmeca Emerald scanning
module.
Fig. 22
Mirror contralateral tooth
feature.
Fig. 23
Software best algorithm
alignment using the
3 common points of the
intraoral impression STL
and CBCT scan.

Fig. 22

Fig. 23

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Fig. 24

Fig. 25

Fig. 26

Fig. 27

Fig. 24
Virtual implant placement.
Fig. 25
Abutment design in Planmeca
Romexis abutment editor.
Fig. 26
Planmeca Romexis surgical
guide module.
Fig. 27
Tooth segmentation feature in
Planmeca Romexis.

Fig. 28

Fig. 29

Fig. 30

Fig. 28
Segmented tooth and root
mirrored and then overlaid in
Meshmixer.
Fig. 29
Combined CBCT segmented
tooth and digital wax-up.
Fig. 30
Sectioned tooth at the margin
of the abutment.

5. All elements are exported as STL files, 9. The new restoration is exported for additive

including the implant location, abutment,
or subtractive manufacturing and the fit versurgical guide, intraoral scan, mirror tooth
ified on the temporary abutment (Fig. 33).
Owing to timing, the restoration is not attached
wax-up and contralateral root.
6. Using Meshmixer, a mirror image of the segto the abutment until the day of surgery.
mented root is produced and then merged 10. Therefore, after the initial consultation and
with the digital wax-up (Figs. 28–30).
data collection, a surgical guide is printed
7. The new mesh is made solid and sliced right
and a pre-surgical provisional restoration is
at the location of the margin in the exported
fabricated using a mirror image of both the
abutment from the implant planning softclinical crown of the contralateral tooth and
ware (Fig. 31).
the root to gain a natural emergence profile.
8. The crown and the cylinder are selected and 11. The surgical guide in this case was exported
a Boolean difference function is performed
from Planmeca Romexis and printed using
to subtract the cylindrical shape from the
Dental LT Clear Resin (Formlabs) with the
crown (Fig. 32).
Form 2 printer (Formlabs).
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Fig. 31

Fig. 32

Fig. 33

Fig. 31
Transparent view
in Meshmixer.
Fig. 32
Tooth with hole after Boolean
difference operation.
Fig. 33
Printed and characterized
tooth on stock temporary
abutment.
Fig. 34
3-D printed surgical guide.

Fig. 34

Fig. 35
The implant is placed after the
manufacturer’s osteotomy
sequence has been performed.

Fig. 35

During the surgical procedure the guide is evaluated for fit, and a flapless approach is taken
(Fig. 34). After the osteotomy the implant is
placed through the guide to the proper depth
(Figs. 35 & 36). The manufacturer’s temporary
abutment is seated, the custom pre-surgical
provisional restoration is seated and flowable
resin composite is injected around the space of
the provisional restoration and abutment
(Figs. 37 & 38). The restoration is removed, polished and reseated for delivery (Fig. 39), and the
access screw channel is covered with PTFE tape
and composite resin.

emergence profiles to achieve adequate esthetics and function; an inadequate emergence
profile can lead to food impaction, gingivitis
and possible peri-implantitis. The use of CAD/
CAM technologies allows clinicians to have
predictable results in a consistent manner
allowing the clinicians to also reduce chair time
and be more efficient.

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

Conclusion
Acknowledgments
Even though particular CAD/CAM systems
were used in the workflow described, the user
is able to use other open architecture systems
and software to develop the techniques. The
techniques described in this article can be used
in every implant case to guide soft-tissue

The authors would like to thank the following
companies for their support in this case report
and for their support in research, education and
innovation: Blue Sky Bio, Medit, Planmeca,
Asiga, Roland, Exocad, DESS and SprintRay.

Journal of
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[16] =>
G u i d e d s o f t - t i s s u e c o n t o u r i n g u s i n g C A D/C A M

Fig. 36

Fig. 37

Fig. 38

Fig. 36
Flapless approach and
implant placement.
Fig. 37
Placement of temporary
titanium abutment.

Fig. 39

References

Fig. 38
Pre-surgical provisional
restoration pressed to
depth in the temporary
abutment and picked up
with flowable resin.

1.
Smith D, Zarb G. Criteria for success of
osseointegrated endosseous implants.
→ J Prosthet Dent.
1989 Nov;62(5):567–72.
2.
DeRouck T, Collyns K, Wyn I, Cosyn J.
Instant provisionalization of immediate
single-tooth implants is essential to
optimize esthetic treatment outcome.
→ Clin Oral Implants Res.
2009 Jun;20(6):566–70.

Fig. 39
Frontal view of restoration
immediately after
delivery.

3.
Gamborena I, Blatz MB. Evolution:
contemporary protocols for anterior
single-tooth implants.
→ Chicago: Quintessence;
2015. 618 p.
4.
Abrahamsson I, Berglundh T, Lindhe J.
The mucosal barrier following abutment
dis/reconnection. An experimental study
in dogs.
→ J Clin Periodontol.
1997 Aug;24(8):568–72.
5.
Lazzara RJ. Immediate implant
placement into extraction sites: surgical
and restorative advantages.
→ Int J Periodontics Restorative Dent.
1989;9(5):332–43.

16 Volume 4 | Issue 4/2018

Journal of
Oral Science & Rehabilitation


[17] =>
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[18] =>
Graftless implant rehabilitation of atrophic maxillae

Implant-supported fixed full-arch
rehabilitation without bone grafting in
severely atrophic maxillae: A 10- to 12-year
retrospective follow-up study
Abstract
Objective
Javier Aizcorbe Vicente,a David Peñarrocha Oltra,a
Eugenia Candel Martí,a Fabio Camacho Alonso,b
Luigi Canulloa, c & María Peñarrocha Diagoa
a

Oral Surgery Unit, Department of Stomatology,
Faculty of Medicine and Dentistry, University of
Valencia, Valencia, Spain
b
Oral Surgery Unit, Department of Stomatology, University
of Murcia, Murcia, Spain
c
Independent researcher, private practice, Rome, Italy

Corresponding author:
Dr. David Peñarrocha Oltra
Cirugía Bucal
Clínica Odontológica de la Universitat de Valencia
C/ Gascó Oliag 1
46021 Valencia
Spain

The objective of this article is to assess the clinical, radiographic and
patient-related outcomes of patients with severe atrophy of the maxilla
(Cawood and Howell Class V) rehabilitated with fixed full-arch prostheses
on dental implants placed in anatomical buttresses and remnant bone.
Materials and methods

An observational retrospective clinical study was performed with a minimum follow-up period of 10 years. An analysis of the following parameters was performed: (a) periimplant parameters (plaque index, modified
gingival index, probing pocket depth and keratinized mucosa width);
(b) marginal bone loss; (c) implant survival rate; and (d) patient satisfaction based on a visual analog scale (VAS).
Results

dpenarrocha@gmail.com
How to cite this article:
Aizcorbe Vicente J, Peñarrocha Oltra D, Candel Martí E,
Camacho Alonso F, Canullo L, Peñarrocha Diago M.
Implant-supported fixed full-arch rehabilitation without
bone grafting in severely atrophic maxillae:
A 10- to 12-year retrospective follow-up study.
J Oral Science Rehabilitation. 2018 Dec;4(4): 18–25.

Ten patients and 71 dental implants were studied, with a mean follow-up
period of 126 months (range: 120–144). The mean plaque index was
1.0 ± 0.5, with a mean probing pocket depth of 2.3 mm (range: 1.0–4.0 mm).
Sixty-one percent and 39% of the implants presented a modified gingival
index of 1 and 2, respectively, and the mean keratinized mucosa width
was 5.8 mm (range: 4.0–10.0 mm). The mean marginal bone loss of the
implants was 0.7 ± 0.4 mm (range: 0.0–5.0 mm). The implant survival
rate was 97.2%, and the overall mean patient satisfaction score was
90 (range: 0–100). Prosthesis cleaning ease scored lowest on the VAS.
Conclusion

In our limited sample of patients with severe maxillary atrophy (Cawood
and Howell Class V), the placement of dental implants in anatomical
buttresses and remnant bone, associated with rehabilitation with fixed
full-arch prostheses, was found to be an adequate treatment option in
the long term regarding implant survival, marginal bone loss, periimplant
clinical parameters and patient satisfaction.

Keywords

Dental implants; atrophic maxilla; fixed prosthesis; full arch; long-term;
graftless.
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Graftless implant rehabilitation of atrophic maxillae

Introduction
Tooth loss gives rise to gradual resorption of the
alveolar process, with a change in bone and
muscle relations and in facial morphology.1
While most of this resorption occurs in the first
year after tooth loss, it continues throughout life
and can often give rise to severe bone atrophy
both vertically and horizontally.2 Severe bone
atrophy of the maxilla (Cawood and Howell
Class V) is associated with certain problems,
such as reduced perioral tissue support, the
impossibility of wearing complete dentures,
chewing and speech alterations, and difficulties
in placing dental implants owing to the limited
amount of available bone.3
Many surgical techniques have been proposed for the rehabilitation of this type of
patient. These methods can be classified into
bone grafting techniques (i.e., guided bone
regeneration,4 onlay grafting with autogenous
bone blocks,5, 6 and inlay autogenous bone grafting7), distraction osteogenesis, 8 crestal expansion techniques (i.e., split crest 9), the use of
special implants (i.e., short dental implants of
< 6 mm or narrow dental implants of < 3 mm10)
and the modification of the original implant
insertion protocol to avoid bone grafting by using
areas of residual bone or anatomical buttresses
(i.e., zygomatic implants,11, 12 pterygoid implants,13
implant insertion in the maxillary tuberosity,14
tilted implants,15 palatal implants16, 17 and implants
placed in the nasopalatine canal18).
The use of bone grafting to allow implant
placement in atrophic maxillae is associated
with more frequent complications and higher
morbidity, especially when an extraoral donor
site is required.19 The associated increase in
financial costs and a longer treatment time
can lead, sometimes, to limited patient acceptance of treatment. Additionally, the use of
extraoral grafts (i.e., iliac crest) has a nonpredictable resorption pattern, which can be
of almost the entire graft, especially in the
edentulous maxilla. 20 The use of short and
narrow implants is a promising alternative
concept for the treatment of the atrophic
maxilla, but the lack of trials for this specific
situation with follow-ups of at least 5 years
indicate caution regarding results. 21
The use of anatomical buttresses and the
residual bone is a predictable way to rehabilitate
the atrophic maxilla with dental implants and
fixed full-arch prostheses, and several studies
detail these techniques. 22–28 This approach

avoids complications and morbidity associated
with bone grafting, reduces treatment costs and
time, and results in a high patient satisfaction
overall.29, 30 Nevertheless, these types of techniques are not free of complications and an
expert surgeon is required, especially for zygomatic implants.12, 31, 32 Because the anatomy of
the atrophic maxilla is different for each patient,
it is usual in daily practice that only 1 graftless
approach is insufficient, and the combined use
of different techniques is essential. However, a
lack of studies combining different implant
approaches in the same patient exists. For this
reason, we sought to study the combined use of
different techniques to treat the Cawood and
Howell Class V atrophic maxilla and their results
in the long term.
The aim of this observational retrospective
clinical study was to evaluate the implant survival rate, clinical and radiographic outcomes,
and patient satisfaction in patients with severe
atrophy of the maxilla rehabilitated with
dental implants placed in anatomical buttresses and remnant bone and supporting a
full-arch fixed prosthesis with a follow-up of
at least 10 years.

Materials and methods
An observational, retrospective clinical study
was performed in the Oral Surgery Unit of the
University of Valencia, Valencia, Spain, from
January 2017 to January 2018, involving patients
with severe atrophy of the maxilla and subjected
to dental implant rehabilitation. A retrospective
chart review was performed to select potential
candidate patients. The following inclusion
criteria were established:
(a) severe atrophy of the maxilla (Cawood and
Howell Class V; the minimum amount of
bone for implant placement was 8 mm in
height and 3 mm in width, measured at
crestal level) treated with dental implants
placed in buttresses and in remnant bone;
(b) rehabilitation with full-arch fixed prosthesis;
(c) good general health; and
(d) a minimum follow-up of 10 years after prosthesis delivery.
Before inclusion in the study, the patients
received an explanation of the scope and purposes of the study and were asked to sign an
informed consent and data confidentiality
form.

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Graftless implant rehabilitation of atrophic maxillae

Figs. 1A & B

A

B
Figs. 1C & D

C

Figs. 1A–D
Patient shows severe periodontal disease and maxillary
atrophy. Treatment plan
consists of the extraction of
maxillary remnant teeth
and the immediate installation
of 6 implants for a fixed fullarch rehabilitation.
(A) Occlusal view of the
maxilla before surgery.
(B) Initial panoramic
radiograph before surgery.
(C) After flap elevation,
2 pterygoid implants and
4 anterior post-extractive
palatal implants were placed.
(D) Panoramic radiograph
after implant placement.

D

Surgical technique

Study variables

Before surgery, a panoramic radiograph and a
cone beam computed tomography or computed
tomography scan was taken of all patients to
assess the amount of remaining bone and the
presence or absence of maxillary sinus disease.
Phibo TSA dental implants with the Avantblast
surface (Phibo Dental Solutions) were used. The
implants were placed with a combination of
drills and osteotomes and were all left submerged (Fig. 1 illustrates a representative clinical
case). Sutures were removed 1 week after surgery, and all patients were included in a maintenance program with control visits involving
professional prophylaxis every 6 months.

Data were collected on patient age and sex, the
number of implants and their dimensions, complications, and the date of prosthesis delivery.
During the last follow-up visit all the prostheses
were removed and the following parameters
were recorded:
Clinical parameters: (a) plaque index;
(b) modified gingival index according to the
specifications of Mombelli;33 (c) probing pocket
depth (measured at 4 points for each implant
and the average calculated); (d) width of keratinized mucosa in millimeters; and (e) the implant
survival rate.
Radiographic parameters: Periapical radiographs obtained at prosthesis delivery and after
at least 10 years were used to calculate bone
loss. Radiographs were obtained with the
XMIND intraoral system (Groupe Satelec-Pierre
Rolland) and an RVG intraoral digital receptor
(Dürr Dental). Periapical radiographs were taken
using the paralleling technique with a film holder
and an aiming device (Rinn XCP, Dentsply Sirona).
If the bone level around the study implants was
not clearly visible, a new radiograph was taken.
Periimplant marginal bone levels were measured
by the same operator, using CliniView software

Prosthetic procedure

Healing abutments were connected 3 months
after implant placement, and the definitive
impressions were obtained 15 days later for
preparation of the definitive full-arch screwretained fixed maxillary prosthesis. Implant
loading took place 5–6 months after surgery.
Fixed hybrid metal–ceramic or fixed hybrid
metal–resin prostheses were used for the definitive restoration.
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Graftless implant rehabilitation of atrophic maxillae

Figs. 1E & F

E

F

(Version 5.1, Instrumentarium Imaging). Each
image was calibrated using the known diameter
of the implants. The vertical distance from the
outer edge of the implant shoulder (reference
point) to the most coronal bone-to-implant contact was measured to the nearest 0.1 mm. From
this measurement, we subtracted the measurement of the polished neck of the implant (1.5 mm)
to determine exactly the beginning of the treated
part. Periimplant marginal bone resorption at
the mesial and distal aspect of the implants was
calculated from the change in bone level between
the baseline (prosthesis delivery) and the last
control radiograph available (at least 10-year
control); for each pair of measurements, the
largest value was used.
Patient-related outcomes: Patient satisfaction was subjectively scored with a visual analog
scale (VAS; range: 1–100) used at the time of the
study. 34–36 This scale assessed patient satisfaction with the implant-supported prosthesis,
measuring the following items: overall satisfaction, comfort and stability, ease of hygiene, ease
of speech, esthetics, self-esteem, and function.
The patients scored these aspects independently, though a dentist was present in case
help or some explanation was needed.

Results
Ten patients with a mean age of 57 years (range:
33–72 years) were included. Of them, 5 were
men and 5 women. A total of 71 dental implants
were placed in the maxilla (between 6 and 8
implants per patient), with dimensions between
8 . 5 × 5. 5 mm and 16.0 × 4. 2 mm. Of these

71 implants, 32 were placed in residual alveolar
bone, 3 in the nasopalatine canal, 16 in the pterygomaxillary region, 12 in a palatal position, and
8 simultaneous to a sinus lift procedure, just to

obtain bicortical anchorage but without the use
of any type of graft (1-stage sinus lift). The mean
duration of follow-up was 126 months (range:
120 –144 months). At the time of the study,
7 patients had been followed up on for 10 years,
1 patient for 11 years, and 2 for 12 years. None of
the patients suffered postoperative complications. Nine patients received hybrid metal–resin
prostheses and 1 a hybrid metal–ceramic prosthesis. Regarding prosthesis complications,
resin fracture occurred in 2 patients (1 year after
loading in 1 case and 4 years after loading in the
other), and the problem was solved with simple
composite repair (Table 1).
Table 2 shows the main findings of the study.
The mean plaque index was 1.0 ± 0.5, with a
mean probing pocket depth of 2.3 mm (range:
1.0–4.0 mm). Sixty-one percent and 39% of the
implants presented a modified gingival index of
1 and 2, respectively, and the mean keratinized
mucosa width was 5.8 mm (range: 4.0–10.0 mm).
One nasopalatine implant failed before prosthetic loading, and 1 implant placed in residual
alveolar bone failed after loading. The implant
survival rate was 97. 2%. The mean marginal
bone loss was 0.7 ± 0.4 mm (range: 0.0–5.0 mm),
with no differences between implant positions.
The overall mean patient satisfaction score was
90 (range of the VAS: 0 –100). Comfort and
stability, function and self-esteem items had the
mean highest values (92 , 95 and 91, respectively). Prosthesis cleaning ease scored lowest
(mean: 72) on the VAS.

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Figs. 1E & F
(E) Occlusal view of the
periimplant soft tissue before
definitive prosthesis delivery.
(F) Occlusal view of the fitted
screw-retained hybrid metal–
resin prosthesis.


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Graftless implant rehabilitation of atrophic maxillae

Figs. 1G & H

G

H
Fig. 1I

Figs. 1G–I
(G) Control panoramic
radiograph showing correct
prosthetic fit.
(H) Occlusal view of the
periimplant soft tissue at
the 10-year control.
(I) Panoramic radiograph
at the 10-year control.

I

Discussion
Severe maxillary atrophy poses problems for
conventional implant placement.37 Bone grafts
are an option in such cases, but are not popular
among patients, owing to the long treatment
times involved, the difficulties and complications
related to the surgical procedure and an increase
in the treatment cost. 38
Conventional dental implant placement in
remnant bone is an effective alternative for the
rehabilitation of these individuals. In this regard,
the survival rate for implants in remnant bone
is greater than for implants in grafted bone.
Widmark et al. reported a survival rate of 87%
with conventional implant placement in atrophic
maxillae, versus 74% in the case of implants in
grafted bone, after a follow-up period of
3–5 years. 39 Rosén and Gynther in turn conducted a study of 19 patients with a mean duration of follow-up of 8–12 years and reported a
survival rate of 97 %. 38 They concluded that
implant placement in the remnant bone of atrophic maxillae is an adequate alternative to bone
grafting procedures. In a study by Krekmanov
22 Volume 4 | Issue 4/2018

et al. involving 22 patients, the survival rate was
found to be 95.7% after a follow-up period of
1–5 years.40 More recently, Testori et al. reported
a survival rate of 95.1% in a sample of 144 implants
placed in atrophic maxillae with a follow-up of
10 years.15 In our study, the implant survival rate
was 97.2% after a mean duration of follow-up
of 126 months. Regarding implant position, the
survival rate of the implants placed in the nasopalatine canal was especially lower. In the literature, the survival rate of this type of implant
was between 84.6% and 100%.18, 41 In our study,
the survival rate in this regard was 66.66%.
These results can be explained by the limited
number of implants (n = 3).
Regarding bone loss, most authors have
reported values similar to those of our own
series. Aparicio et al. studied 101 conventional
implants in 25 patients with atrophic maxillae
and recorded a mean bone loss of 1.21 mm after
37 months of follow-up. 42 A study by Toljanic et
al. recorded a mean bone loss of 0.9 ± 0.8 mm
in 46 patients after 1 year of follow-up. 43 This
figure remained stable from fitting of the prosthesis to 1 year of follow-up. Testori et al.

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Graftless implant rehabilitation of atrophic maxillae

Table 1

Patient

Age (years)

Sex*

No. of implants

Complications

Follow-up (months)

1

55

M

6

None

120

2

72

F

7

None

144

3

61

F

7

Prosthesis fracture

120

4

51

M

8

Prosthesis fracture

120

5

33

F

8

None

144

6

70

F

6

None

120

7

65

M

7

None

120

8

44

F

7

None

120

9

61

M

7

None

120

10

58

M

8

None

132

* M = male; F = female.

Table 2

N

PI

PPD

GI

KMW

IS

MBL

PS

71

1.0 ± 0.5

2.3 mm
(range: 1.0–4.0 mm)

1–61%
2–39%

5.8 mm
(range: 4.0–10.0 mm)

97.2%

0.7 ± 0.4 mm
(range: 0.0–5.0 mm)

90

PI = plaque index; PPD = probing pocket depth; GI = modified gingival index; KMW = keratinized mucosa width; IS = implant survival; MBL = marginal bone loss; PS = patient satisfaction.

analyzed tilted and axial implants in 41 patients
with atrophic maxillae; after a follow-up period
of 12 months, they recorded a mean bone loss
of 0. 9 ± 0. 4 mm in axial implants and of
0.8 ± 0.5 mm in tilted implants. 44 In our study,
a mean marginal bone loss of 0.7 ± 0.4 mm was
observed, in accordance with the literature.
Patient satisfaction was very high, since the
procedure proved less invasive and the treatment times were shorter than with other treatment options. In a study by Peñarrocha et al.,
patients with severe maxillary atrophy rehabilitated with angled and palatine implants showed
very high satisfaction scores owing to the
reduced time, cost and morbidity associated
with the treatment provided. 45 Erkarpers et al.
likewise recorded very high satisfaction scores
in patients with atrophic maxillae rehabilitated
with conventional implants and immediate
loading.46 The worst result in the present study
was obtained for ease of cleaning (72 VAS). In
this regard, it is important to ensure that the
prosthesis design is easy to clean for patients
that usually do not have adequate hygienic skills.
The major limitation of the present observational retrospective clinical study was the small
sample of patients (N = 10). It is necessary to
carry out studies with larger samples to confirm
these results.

Conclusion
In our limited sample of patients with severe
maxillary atrophy (Cawood and Howell Class V),
the placement of dental implants in anatomical
buttresses and remnant bone, rehabilitated with
fixed full-arch prostheses, was found to be an
adequate treatment option in the long term
regarding implant survival, marginal bone loss
and periimplant clinical parameters. Patient
satisfaction was very high; however, it is important to design hygienic (flat or convex) prostheses
to facilitate cleaning by the patient at home.

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

Journal of
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Volume 4 | Issue 4/2018 23

Table 1
Description of the study
sample.
Table 2
Results.


[24] =>
Graftless implant rehabilitation of atrophic maxillae

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Watzek G. Graftless full-arch implant
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2016 Jul–Aug;31(4):900–5.
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rehabilitation with interantral implants
and immediate or delayed loading—part II:
transition from the failing maxillary
dentition.
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2016 Sep–Oct;31(5):1150–5.
25.
Candel-Marti E, Peñarrocha-Oltra D,
Bagán L, Peñarrocha-Diago MA,
Peñarrocha-Diago M. Palatal positioned
implants in severely atrophic maxillae
versus conventional implants to support
fixed full-arch prostheses: controlled
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of follow-up.
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Maló P, Rangert B, Nobre M. All-on-4
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Peñarrocha M, Viña JA, Carrillo C,
Peñarrocha D, Peñarrocha MA.
Rehabilitation of the reabsorbed maxillae
with implants in buttresses in patients
with combination syndrome.
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2012 May;70(5):e322–30.
29.
Candel-Marti E, Peñarrocha-Oltra D,
Peñarrocha-Diago MA, PeñarrochaDiago M. Satisfaction and quality of life
with palatal positioned implants in
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conventional implants supporting fixed
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2015 Nov 1;20(6):e751–6.
30.
Alzoubi F, Bedrossian E, Wong A, Farrell
D, Park C, Indresano T. Outcome
assessment of treating completely
edentulous patients with a fixed
implant-supported profile prosthesis
utilizing a graftless approach.
Part 2: patient-related outcomes.
→ Int J Oral Maxillofac Implants.
2017 Sep–Oct;32(5):1080–5.
31.
Chrcanovic BR, Abreu MH. Survival and
complications of zygomatic implants:
a systematic review.
→ Oral Maxillofac Surg.
2013 Jun;17(2):81–93.
32.
Duarte LR, Filho HN, Francischone CE,
Peredo LG, Brånemark PI. The
establishment of a protocol for the total
rehabilitation of atrophic maxillae
employing four zygomatic fixtures in
an immediate loading system—
a 30-month clinical and radiographic
follow-up.
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2007 Dec;9(4):186–96.
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Mombelli A, Van Oosten MA, Schürch E,
Lang NP. The microbiota associated
with successful or failing osseointegrated titanium implants.
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34.
Heydecke G, Boudrias P, Awad MA, de
Albuquerque RF, Lund JP, Feine JS.
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→ Clin Oral Implants Res.
2003 Feb;14(1):125–30.
35.
Farzad P, Andersson L, Gunnarsson S,
Johansson B. Rehabilitation of severely
resorbed maxillae with zygomatic
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Pjeturssonn BE, Rast C, Brägger U,
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2009 Jul;20(7):667–76.

37.
Barone A, Orlando B, Tonelli P, Covani U.
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2011 Feb;82(2):219–26.
38.
Rosén A, Gynther G. Implant treatment
without bone grafting in edentulous
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39.
Widmark G, Andersson B, Carlsson GE,
Lindvall AM, Ivanoff CJ. Rehabilitation
of patients with severely resorbed
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41.
De Mello, Faot F, Correa G, Chagas Júnior
OL. Success rate and complications
associated with dental implants in the
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Aparicio C, Perales P, Rangert B. Tilted
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→ Clin Implant Dent Relat Res.
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Toljanic JA, Baer RA, Ekstrand K, Thor A.
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fixed provisional restoration without
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2009 May–Jun;24(3):518–26.

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Krekmanov L, Kahn M, Rangert B,
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Testori T, Del Fabbro M, Capelli M,
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[26] =>
Smart Lift technique for sinus floor elevation

A minimally invasive
technique for
transcrestal sinus
floor elevation

Abstract
Background
Leonardo Trombelli,a, b Roberto Farina,a, b
David Peñarrocha Oltrac & Giovanni Franceschettia
a

Research Center for the Study of Periodontal and
Periimplant Diseases, University of Ferrara, Ferrara, Italy
b
Operative Unit of Dentistry, Azienda Sanitaria Locale di
Ferrara, Ferrara, Italy
c
Oral Surgery Unit, Department of Stomatology,
Faculty of Medicine and Dentistry, University of Valencia,
Valencia, Spain

Transcrestal maxillary sinus floor elevation represents an effective surgical option to vertically enhance the available bone in the edentulous
posterior maxilla.
Purpose

The purpose of the present study is to describe a minimally invasive technique for transcrestal sinus floor elevation, the Smart Lift technique,
through a paradigmatic clinical case.

Corresponding author:
Prof. Leonardo Trombelli
Research Center for the Study of
Periodontal and Periimplant Diseases
University of Ferrara
Corso Giovecca 203
44121 Ferrara
Italy
T +39 0532 688500
leonardo.trombelli@unife.it.
How to cite this article:

Conclusion

The Smart Lift technique is based on specially designed drills and osteotomes used with a stop device that restricts the working action to the
residual bone, thus preventing the accidental penetration of instruments
into the sinus cavity. Also, the use of a standardized sequence of instruments has been shown to limit the impact of the clinician’s judgement
and skill, thus allowing for rapid learning for inexperienced clinicians. The
technique is effective to achieve endo-sinusal bone formation with limited
post-surgical morbidity.

Trombelli L, Farina R, Peñarrocha Oltra D,
Franceschetti G. A minimally invasive technique for
transcrestal sinus floor elevation.
J Oral Science Rehabilitation. 2018 Dec;4(4): 26–34.

26 Volume 4 | Issue 4/2018

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Smart Lift technique for sinus floor elevation

Introduction
In the posterior maxillary sextants, the insertion
of implants of desired length and diameter may
be limited by the dimensional alterations of the
bone crest that occur after tooth loss,1 partly
due to the pneumatization of the maxillary
sinus.2 Transcrestal maxillary sinus floor elevation (tSFE) represents an effective surgical
option to vertically enhance the available bone
in the edentulous posterior maxilla. 3, 4

– indications for implant-supported prosthetic
rehabilitation, based on accurate diagnosis and
treatment planning;
– systemic and local conditions that are compatible with implant placement and sinus floor
elevation procedures;
– residual bone height (i.e., the distance from the
bone crest to the sinus floor) that prevents the
insertion of an implant of the desired length
and residual bone height of at least 2 mm.
The Smart Lift technique must not be performed
whenever systemic and local conditions contraindicate sinus floor elevation.

Technique description
The Smart Lift technique was developed by the
Research Center for the Study of Periodontal and
Periimplant Diseases, University of Ferrara,
Ferrara, Italy, and the Department of Odontostomatology, Ospedale “Casa Sollievo della
Sofferenza,” San Giovanni Rotondo, Italy.5, 6 The
technique is characterized by transcrestal access
to the sinus cavity by means of specially designed
drills and osteotomes. The pristine bone at sites
of implant placement is drilled up to the sinus
floor with a trephine bur and then used to fracture the sinus floor by hydraulic pressure through
osteotomes. In this respect, the procedure represents a modification of the technique proposed
by Fugazzotto.7 One of the advantages of the
technique lies in the use of all manual and rotating instruments with adjustable stop devices,
which are selected in relation to the vertical
amount of residual bone at sites where implants
have to be placed. These stop devices have a
variable length and may be adapted to all manual
and rotating instruments. The use of the stop
device restricts the working action of burs and
osteotomes to the vertical amount of residual
bone, thus preventing the accidental penetration
of instruments into the sinus cavity. The determination of the working length (i.e., the distance
from the bone crest to the sinus floor) where the
osteotome and burs have to limit their working
action is first diagnosed on 2-D and/or 3-D radiographs, and then verified intra-surgery by means
of a specially designed osteotome. The second
advantage relates to the standardized sequence
of instruments used for the Smart Lift procedure,
which has been shown to limit the impact of the
clinician’s judgment and skill, thus allowing for
rapid learning for inexperienced clinicians. 8
The Smart Lift technique shares its clinical
indications with the other surgical procedures
for tSFE:

The Smart Lift technique:
Sequence of instruments

According to the prosthetic treatment planning,
the locations for implant placement are established, and the residual bone height at such locations is radiographically measured as the distance from the bone crest to the sinus floor
(radiographic working length).
All instruments in the surgical set are characterized by laser marks at each millimeter to
allow for precise control of the working length.
In the conventional sequence (used with a residual bone height of at least 3 mm; Fig. 1), the first
drill (locator drill) is used to perforate the cortical bone at the site where the implant is to be
placed. A second drill (probe drill), with a diameter of 1.2 mm and cutting only at the top edge,
is used to define the position and orientation of
the implant. In order to minimize the risk of sinus
floor perforation, this bur is used with an adjustable stop device that is set at least 1 mm shorter
than the radiographic working length. The probe
osteotome (∅: 1.2 mm) is carefully inserted into
the site prepared with the probe drill and gently
forced in an apical direction through the cancellous bone until the cortical bone resistance of
the sinus floor is met. Therefore, the probe
osteotome provides the surgical working length,
which is the true anatomical distance from the
bone crest to the sinus floor in the exact location
where the implant should be placed. Thus, the
working action of all manual and rotating instruments that will be used in subsequent surgical
steps must be set at the surgical working length
using the proper adjustable stop device.
A radiographic pin (∅: 1.2 mm) can be used to
check direction and depth of the prepared site
by means of a periapical radiograph. The radiographic pin handle has a diameter of 4 mm, thus

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Smart Lift technique for sinus floor elevation

Fig. 1

Fig. 1
Conventional sequence of the
Smart Lift technique (residual
bone height ≥ 3 mm5, 6).

permitting evaluation of the spatial relationship
between the prepared site and the buccolingual
and mesiodistal dimensions of the alveolar ridge.
This will help the clinician to determine the diameter of the implant to be placed.
A guide drill with a diameter of 3. 2 mm
(implant ∅: 3.75 - 4.50 mm) or 4.0 mm (implant
∅: 4.5 mm or larger) is then used. This drill follows the 1.2 mm diameter site preparation and
creates a crestal countersink, where the trephine
bur (Smart Lift drill) will be inserted. Such a
countersink will force the trephine bur to follow
the desired direction. The Smart Lift drill (∅: 3.2
or 4.0 mm), set at the surgical working length,
produces a bone core up to the sinus floor. The
bone core and a variable amount of particulate
bone substitute are condensed and malleted to
fracture the sinus floor by means of a calibrated
osteotome (Smart Lift elevator, ∅: 3.2 or 4.0 mm)
that corresponds to the diameter of the trephine
preparation. If the alveolar bone core is found to
be inside the trephine, the bone core is gently
removed from the trephine and replaced in the
bone preparation. The osteotome is used under
gently malleting forces to implode the trephined
bone core over the sinus floor. In relation to the
extent of vertical bone augmentation to be
achieved, an autogenous cortical bone particulate or a particulate bone substitute can be further grafted and condensed into the sinus with
the osteotome. Again, the Smart Lift elevator is
used with the proper stop device at the surgical
working length, thus preventing any unwanted
28 Volume 4 | Issue 4/2018

penetration of the instruments into the sinus
cavity. Provided that the residual bone may
ensure an adequate primary stability, an implant
can be inserted during the same surgical session.
Otherwise, a staged approach is recommended.
If the residual bone height is 2 mm, a modified
sequence must be adopted.9 The mean duration
of the sinus floor elevation procedure (from cortical perforation to the completion of the grafting procedure), as reported in different cohort
and randomized controlled trials, ranged
between 19 and 32 min.6, 8, 10–13
In a recent study, 8 patients treated with the
Smart Lift technique by 3 operators with different levels of experience in implant surgery and
inexperienced with respect to the Smart Lift
technique, showed a substantial extent of sinus
elevation in a limited operation time, along with
minimal incidence of membrane perforation and
post-surgical dosage of anti-inflammatory drugs.8
The clinical application of the Smart Lift
technique is illustrated in Figure 2 .
The Smart Lift technique:
Clinical outcomes

The Smart Lift technique was first reported in
2008. 5 During the last 10 years, several studies
have been conducted,5, 6, 8, 9, 11–16 reporting data
on treatment outcomes and post-surgical morbidity of the procedure (Table 1). Only in 1 case
did the Smart Lift technique not allow for the
placement of implant concomitant to tSFE13 and

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Smart Lift technique for sinus floor elevation

Fig. 2A

A
Figs. 2B & C

B

C

Figs. 2D & E

D

implant insertion had to be delayed owing to the
lack of primary stability. Implant survival shifted
from 100% at 6 months in 8 studies5, 6, 8, 10–12, 15, 16
to 94% at 12 months in 1 study.13 The length of
the inserted implants varied between 9.06 and
10.3 mm,10 and the height of the residual bone
ranged from 4.513 to 6.6 mm.5 The extent of sinus
lift ranged from 5.38 to 7.7 mm.11
The Smart Lift technique:
Post-surgical morbidity

The mean scores for post-surgical pain and discomfort, as reported on a 100 mm visual analog
scale,17 ranged from 0 to 62 mm and from 0 to
17 mm, respectively.8, 11 The level of pain significantly decreases, starting from the first day

E

post-surgery,13 and reaches very low levels (ranging from 1.0 to 2.1 mm) at the seventh day.6, 8, 10–13
Six studies have reported data on intra- and
post-surgical complications.10–13 Membrane perforation was the most frequent complication,
with the incidence ranging from 011 to 13%.12 In
all cases, the perforation was managed with the
insertion of a surgical hemostatic dressing
(Gingistat, GABA Vebas) or a collagen matrix
(Mucograft Seal, Geistlich Pharma). In all cases,
the grafting procedure was completed and the
implant was inserted. Rarely, other types of complications, such as transitory paresthesia in the
suborbital area (1 case),15 tinnitus (1 case)15 and
benign paroxysmal positional vertigo (1 case)12
occurred. All these complications spontaneously
subsided within the first week post-surgery.

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Figs. 2 A–E
A 52-year-old male patient
presented with an edentulous
area in the maxillary right
quadrant. Neither systemic nor
local conditions contraindicating implant surgery or sinus
lift procedures were identified
at the screening visit. The
prosthetic rehabilitation plan
included the placement of
2 implant-supported crowns in
the region of the maxillary
right second premolar and first
molar, which had been
extracted 3 years prior to
the visit.
(A) Computed tomography
scans showed a radiographic
working length of 2.7 mm at
the first molar site and 7.6 mm
at the second premolar site.
(B) Lateral clinical photograph.
(C) Occlusal clinical photograph.
(D) The surgical working
length assessed at
the position of the second
premolar was 6 mm as
diagnosed with the probe
osteotome. Therefore,
a tSFE procedure was
performed also at this site.
(E) A countersink was
prepared with the guide drill.


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Smart Lift technique for sinus floor elevation

Figs. 2F–I

F

G

H

I
Figs. 2J–L

Figs. 2F–P
(F–I) A trephined bone core
was created with the
Smart Lift drill with a diameter
of 3.2 mm.
(J–L) The bone core, along
with a bone substitute
(Bio-Oss spongiosa granules,
particle size of 0.25–1.00 mm,
500 mg package; Geistlich
Pharma), was gently malleted
using the 3.2 mm diameter
Smart Lift elevator with the 6
mm stop device until the sinus
floor was fractured.
(M) At the distal implant site,
the surgical working length
was 2 mm as assessed using
the probe osteotome.
(N) A countersink created with
the guide drill superficially
marked the area for the Smart
Lift elevator.
(O) The residual bone was
gently malleted into the sinus
with the Smart Lift elevator.
(P) A 3-D collagen matrix
(Mucograft Seal) was trimmed
and inserted into the crestal
access.

J

K

L
Figs. 2M & N

M

N
Figs. 2O & P

O

30 Volume 4 | Issue 4/2018

P

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Smart Lift technique for sinus floor elevation

Figs. 2Q–S

Q

R

S

Figs. 2T–V

T

U

V

Figs. 2W & X

W

X

Y

Z

Figs. 2Q–Z
(Q–S) The grafting procedure
was performed by repeated
insertion of the bone
substitute by means of the
Smart Lift elevator.
(T–V) Two implants
(9.5 × 3.5 mm and
8.0 × 4.0 mm; SPI Element
Inicell, Thommen Medical)
were inserted at the second
premolar and first molar sites,
respectively. The distal
implant was slightly angulated
in order to enhance primary
stability.
(W–Z) Clinical and radiographic aspects of the
rehabilitated sites at 1 and
3 years post-surgery.

Figs. 2Y & Z

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Smart Lift technique for sinus floor elevation

Table 1

Follow-up
period
(months)

Implant
survival (%)

Authors

Type of study

No. of patients

No. of
implants

Farina et al.13

RCCT (tSFE group)

29

33

12

94%

Franceschetti et al.16

Retrospective case series

14

14

6

100%

Initial group

13

13

6

100%

Final group

13

13

6

100%

Expert
operator
group

20

20

6

100%

Moderately
experienced
operator
group

20

20

6

100%

Low
experienced
operator
group

20

20

6

100%

DBBM group

19

19

6

100%

ȕ-TCP group

19

19

6

100%

Smoker
group

25

25

6

96%

Nonsmoker
group

20

20

6

100%

S-HA group

15

15

6

100%

DBBM group

15

15

6

100%

Franceschetti et al.8

Trombelli et al.12

Franceschetti et al.15

Trombelli et al.11

Prospective
case series

RCCT

Prospective
cohort study

RCCT

Trombelli et al.10

Case series

11

14

6

100%

Trombelli et al.6

Case report

1

1

6

100%

Trombelli et al.5

Case report

1

1

6

100%

RCCT = randomized controlled clinical trial; tSFE = transcrestal maxillary sinus floor elevation; DBBM = deproteinized bovine bone mineral;
TCP = tricalcium phosphate; ND = no data; IR = interquartile range; S-HA = synthetic hydroxyapatite.

Table 1
Studies reporting data on
treatment outcomes of the
Smart Lift technique.
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Smart Lift technique for sinus floor elevation

Implant length (mm) expressed as
median (IR) or mean (± SD)

Residual bone height (mm)
expressed as median (IR)
or mean (± SD)

Immediate post-surgical extent of
sinus lift (mm) expressed as
median (IR) or mean (± SD)

Immediate post-surgical height
of graft apical to implant
apex (mm) expressed as median
(IR) or mean (± SD)

9.5 (9.5–9.5)
(median) (IR)

4.5 (4.0–5.3)
(median) (IR)

ND

0.9 (0.3–1.6)
(median) (IR) (27 patients)

9.8 (9.5–11.0)
(median) (IR)

6.0 (5.6–6.8)
(median) (IR)

6.8 (5.7–7.6)
(median) (IR)

ND

ND

6.3 (± 1.6)
(mean) (SD)

6.6 (± 1.8)
(mean) (SD)

2.9 (± 1.1)
(mean) (SD)

ND

5.8 (± 0.9)
(mean) (SD)

7.0 (± 1.3)
(mean) (SD)

2.5 (± 1.5)
(mean) (SD)

ND

5.4 (± 1.2)
(mean) (SD)

7.2 (± 1.2)
(mean) (SD)

2.6 (± 1.2)
(mean) (SD)

ND

6.4 (± 1.3)
(mean) (SD)

6.0 (± 1.9)
(mean) (SD)

2.3 (± 1.3)
(mean) (SD)

ND

5.2 (± 1.6)
(mean) (SD)

5.3 (± 1.4)
(mean) (SD)

2.0 (± 0.8)
(mean) (SD)

9.5 (9.5–11.0)
(median) (IR)

5.4 (5.0–6.1)
(median) (IR)

6.1 (5.6–6.9)
(median) (IR)

1.5 (1.2–2.3)
(median) (IR)

9.5 (9.5–11.0)
(median) (IR)

5.5 (5.2–6.8)
(median) (IR)

6.8 (6.2–7.5)
(median) (IR)

2.2 (1.6–3.1)
(median) (IR)

9.5 (9.5–10.3)
(median) (IR)

5.3 (4.7–5.8)
(median) (IR)

6.9 (6.0–7.7)
(median) (IR)

2.5 (1.7–3.4)
(median) (IR)

9.5 (8.5–10.0)
(median) (IR)

5.0 (4.2–6.1)
(median) (IR)

6.5 (5.7–7.7)
(median) (IR)

2.3 (1.3–2.8)
(median) (IR)

10.0 (8.75–10.50)
(median) (IR)

5.25 (4.6–6.4)
(median) (IR)

7.7 (6.70–8.55)
(median) (IR)

3.0 (2.80–3.75)
(median) (IR)

9.5 (9.5–10.0)
(median) (IR)

5.7 (4.33–6.35)
(median) (IR)

6.5 (5.95–7.40)
(median) (IR)

2.6 (2.30–3.45)
(median) (IR)

10.3 (± 0.9)
(mean) (SD)

6.1 (± 1.8)
(mean) (SD)

ND

ND

9.0

5.0

ND

ND

ND

6.6

ND

ND

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Smart Lift technique for sinus floor elevation

Conclusion

a simplified, user-friendly, standardized procedure that allows for a substantial extent of sinus
In the edentulous maxillary posterior sextants, lift with limited post-surgical morbidity.
the vertical dimension of the residual bone crest
may frequently call for bone augmentation procedures to allow for the placement of implants
Competing interests
of adequate length and width. Among the techniques for tSFE that have been proposed in the The authors declare that they have no competliterature, the Smart Lift technique represents ing interests.

References
1.
Pramstraller M, Farina R, Franceschetti
G, Pramstraller C, Trombelli L. Ridge
dimensions of the edentulous posterior
maxilla: a retrospective analysis of
a cohort of 127 patients using
computerized tomography data.
→ Clin Oral Implants Res.
2011 Jan;22(1):54–61.
Erratum in: Clin Oral Implants Res.
2011 Feb;22(2):235.
2.
Farina R, Pramstraller M, Franceschetti
G, Pramstraller C, Trombelli L. Alveolar
ridge dimensions in maxillary posterior
sextants: a retrospective comparative
study of dentate and edentulous sites
using computerized tomography data.
→ Clin Oral Implants Res.
2011 Oct;22(10):1138–44.
3.
Romero-Millán J, Martorell-Calatayud L,
Peñarrocha M, García-Mira B.
Indirect osteotome maxillary sinus floor
elevation: an update.
→ J Oral Implantol.
2012 Dec;38(6):799–804.
4.
Pjetursson BE, Lang NP. Sinus floor
elevation utilizing the transalveolar
approach.
→ Periodontol 2000.
2014 Oct;66(1):59–71.

6.
Trombelli L, Minenna P, Franceschetti G,
Minenna L, Itro A, Farina R. Minimally
invasive technique for transcrestal sinus
floor elevation: a case report.
→ Quintessence Int.
2010 May:41(5):363–9.

10.
Trombelli L, Minenna P, Franceschetti G,
Minenna L, Farina R. Transcrestal sinus
floor elevation with a minimally invasive
technique.
→ J Periodontol.
2010 Jan;81(1):158–66.

7.
Fugazzotto PA. Immediate implant
placement following a modified trephine/
osteotome approach: success rates
of 116 implants to 4 years in function.
→ Int J Oral Maxillofac Implants.
2002 Jan–Feb;17(1):113–20.

11.
Trombelli L, Franceschetti G, Rizzi A,
Minenna P, Minenna L, Farina R.
Minimally invasive transcrestal sinus
floor elevation with graft biomaterials.
A randomized clinical trial.
→ Clin Oral Implants Res.
2012 Apr;23(4):424–32.

8.
Franceschetti G, Trombelli L, Minenna L,
Franceschetti G, Farina R. Learning curve
of a minimally invasive technique for
transcrestal sinus floor elevation:
a split-group analysis in a prospective
case series with multiple clinicians.
→ Implant Dent.
2015 Oct;24(5):517–26.
9.
Trombelli L, Franceschetti G, Trisi P,
Farina R. Incremental, transcrestal sinus
floor elevation with a minimally
invasive technique in the rehabilitation of
severe maxillary atrophy. Clinical and
histological findings from a proof-ofconcept case series.
→ J Oral Maxillofac Surg.
2015 May;73(5):861–88.

5.
Trombelli L, Minenna P, Franceschetti G,
Farina R, Minenna L. Smart-Lift:
a new minimally-invasive procedure
for sinus floor elevation.
→ Dental Cadmos.
2008;76:71–83.

34 Volume 4 | Issue 4/2018

12.
Trombelli L, Franceschetti G, Stacchi C,
Minenna L, Riccardi O, Di Raimondo R,
Rizzi A, Farina R. Minimally invasive
transcrestal sinus floor elevation with
deproteinized bovine bone or ȕ-tricalcium
phosphate: a multicenter, double-blind,
randomized, controlled clinical trial.
→ J Clin Periodontol.
2014 Mar;41(3):311–9.
13.
Farina R, Franceschetti G, Travaglini D,
Consolo U, Minenna L, Schincaglia GP,
Riccardi O, Bandieri A, Maietti E,
Trombelli L. Morbidity following
transcrestal and lateral sinus floor
elevation: a randomized trial.
→ J Clin Periodontol.
2018 Sep;45(9):1128–39.
14.
Trombelli L, Franceschetti G, Farina R,
Itro A. Smart-lift technique used in
association with a hydroxyapatite-based
biomaterial. Clinical outcomes and
postoperative morbidity.
→ Eur J Oral Surg.
2010 Sep;2(1):47–55.

Journal of
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15.
Franceschetti G, Farina R, Stacchi C, Di
Lenarda R, Di Raimondo R, Trombelli L.
Radiographic outcomes of transcrestal
sinus floor elevation performed with
a minimally invasive technique in smoker
and non-smoker patients.
→ Clin Oral Implants Res.
2014 Apr;25(4):493–9.
16.
Franceschetti G, Rizzi A, Minenna L,
Pramstraller M, Trombelli L, Farina R.
Patient-reported outcomes of implant
placement performed concomitantly
with transcrestal sinus floor elevation
or entirely in native bone.
→ Clin Oral Implants Res.
2017 Feb;28(2):156–62.
17.
McCormack HM, Horne DJ, Sheather S.
Clinical applications of visual analogue
scales: a critical review.
→ Psychol Med.
1988 Nov;18(4):1007–19.


[35] =>
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[36] =>
Oral cancer and dental implants

The relationship between oral
squamous cell carcinoma and dental
implants: A literature review
Abstract
Purpose
Ángela Rodríguez Caballero,a Manuel María Romero Ruiz,a
María Angeles Serrera Figallo,a José Luis Gutiérrez Péreza, b
& Daniel Torres Lagaresa
a

Department of Stomatology, University of Seville,
Seville, Spain
b
Virgen del Rocío Hospital, Clinical Management Unit,
Oral and Maxillofacial Surgery, Seville, Spain

The aim of this article is to provide a thorough review of the possible
relationship between dental implants and the incidence of oral cancer,
particularly emphasizing the clinical data, to allow an early diagnosis of
cancer and avoid mistakes in diagnosing cancer or regular periimplant
inflammatory conditions.
Materials and methods

Corresponding author:
Dr. Daniel Torres Lagares
Facultad de Odontología de Sevilla
C/Avicena s/n
41009 Sevilla
Spain
danieltl@us.es
How to cite this article:
Rodríguez Caballero A, Romero Ruiz MM, Serrera Figallo
MA, Gutiérrez Pérez JL, Torres Lagares D.
The relationship between oral squamous cell carcinoma
and dental implants: a literature review.
J Oral Science Rehabilitation. 2018 Dec;4(4):36–44.

A literature search on Medline/PubMed was performed. The criteria for
consideration were articles published between 1999 and 2017, with the
following MeSH terms: “oral squamous cell carcinoma,” “dental
implants,” “osseointegrated,” and “periimplant tumor.” To be considered,
they had to be
1. original studies;
2. clinical trials, meta-analyses, randomized controlled trials, or reviews;
3. on oral squamous cell carcinoma developed around osseointegrated
implants;
4. papers published in English; and
5. studies done in humans.
The papers were selected by the authors of this study and validated by
agreement.
Results

Initially, 143 papers were selected, of which only 12 were kept after
excluding those not matching the inclusion criteria. An average of
2 implants were present in patients between 42 and 80 years old.
Regarding the location of the tumors, 88.23% were located in the lower
jaw, mainly (76.46%) in the posterior area. Only 2 out of the 17 (11.77%)
were located on the edge of the tongue.
Conclusion

An appropriate preoperative study should be done on patients at risk,
and the prosthesis should be designed to allow easy removal for tissue
examination. A histopathological test should be performed in the case
of inflammatory tissue in the periimplant area.
Keywords

Oral cancer; dental implants; relationship.
36 Volume 4 | Issue 4/2018

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Oral cancer and dental implants

Introduction
Oral cancer represents 2 % of all malignant
tumors. Approximately 90% of oral carcinoma
is squamous cell carcinoma of the oral epithelium (OSCC) of the oral epithelium, while the
other 10% is tumors of other histological origin,
being extremely rare malign odontogenic tumors
and metastatic tumors from carcinomas located
at distance.1 Only 1% of oral carcinoma cases
develop metastasis, although metastases in the
hard tissue of the maxillofacial area are more
common compared with those in the soft tissue
(2:1 relation).1, 2 The etiology of OSCC is multifactorial. Oral hygiene and toxic habits such as
alcohol- and tobacco-related factors have been
proven to be involved.2–4 The risk of malignancy
is increased in the presence of oral lesions like
leukoplakia or erythroplakia, lichen planus or
human papillomavirus lesions. Patients with a
previous history of carcinoma also have a greater
risk of developing a second primary neoplasm.4, 5
Implant placement for the oral rehabilitation
of the partially or completely edentulous patient
is nowadays a predictable treatment option and
allows recovery of the loss of esthetics and function. 6, 7 Long-term success rates have been
reported, even in patients particularly difficult to
treat. However, there is no lack of complications
that may occur, and among the most common is
a chronic inflammatory process of both soft and
hard tissue, separately or at the same time.8–12
At the 2008 European Workshop on Periodontology, 2 possibilities of diagnosis were
defined: periimplant mucositis and periimplantitis.13 The former describes an inflammatory
lesion located on the mucosa that is clinically
reddened (erythematosus) and bleeds on probing, although with no bone loss. For periimplantitis, however, there is bone loss in addition to
the other signs and symptoms, and it is commonly associated with suppuration and deep
pockets. Periimplantitis and periimplant mucositis occur in up to 80% of patients and affect
up to 50% of implants. Risk factors for periimplantitis are poor oral hygiene, a history of periodontitis, diabetes mellitus, tobacco use, alcohol
use and genetic predisposition. Of all these risk
factors, only poor oral hygiene and tobacco use
have the best scientific evidence to support their
connection to periimplantitis, the rest of the risk
factors being insufficiently proven.13
There are few published cases on osseointegrated dental implants associated with OSCC;
however, there is scientific evidence to support

that, in some cases, OSCC surrounding dental
implants has a very similar appearance to that
of periimplantitis, with mucosal reddening and
bone loss.
The aim of this research is to perform a
thorough review of the relationship between
OSCC and dental implants, trying at the same
time to identify the various clinical presentations
and the eventual risk factors. It is also intended
to identify at an early stage those clinical elements
that can lead to OSCC, facilitating biopsy and
early diagnosis.

Materials and methods
A search on Medline/PubMed was carried out
on the relationship between dental implants and
OSCC. Regarding the search strategy, papers
published between June 1999 and March 2017,
including these dates, were included. The MeSH
resource was used, selecting as search terms
“oral squamous cell carcinoma,” “dental implants,”
“osseointegrated,” and “periimplant tumor.” The
criteria for selection were
1. original studies;
2. clinical trials, meta-analyses, randomized
controlled trials, or literature reviews;
3. OSCC developed around dental implants;
4. articles published in English;
5. articles of studies in humans.
The articles were selected by the researchers
based on their titles and abstracts and validated
by consensus.”. All those articles related to OSCC
in relation to dental implants (clinical cases with
histopathological tests). Those articles where
the patient’s age, tumor location or type was not
specified were excluded.

Results
Initially, 143 articles were selected, of which 132
did not meet all of the inclusion criteria and
therefore were excluded. In total, 12 articles
were selected14–25 and processed for collection
of data. They were 4 literature reviews, involving
5 clinical cases;15, 23–25 1 longitudinal randomized
case–control trial;20 1 case series;17 and 6 welldocumented case reports.14, 16, 18, 19, 21, 22 The total
number of patients was 34, and a total of 17 case
reports were analyzed.
The patients were aged between 42 and
80 years (mean: 66.3 ± 10.1 years). Of all the case

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Oral cancer and dental implants

reports, 53% of the patients involved were men,
while in the longitudinal randomized study, no
significant differences regarding sex were found.
An average of 4.58 ± 3.57 implants were placed
per patient. In those documented case reports,
a minimum of 2 implants were placed per
patient, while in the longitudinal study,
56 implants were placed in 21 patients. The characteristics of those studies that meet the inclusion criteria are shown in Table 1.
Regarding the location, there was a clear predominance of the lower jaw (88.23%), specifically
the posterior region (76.46%). The tumor was
located on the lingual ridge in only 2 out of the 17
cases (11.77%). The average time between implant
placement and diagnosis of OSCC was 0. 25
months to 120 months (42.81 ± 37.73 months).
Prior to the implant placement, 76.47 % of
the patients presented 1 or more risk factors for
developing a malignancy: 47.06% of cases had
a previous history of oral carcinoma (squamous
cells and verrucous carcinoma of the alveolar
ridge) or cancer in other organs far from the oral
cavity (lung cancer, pancreatic cancer or breast
cancer); 11.76% had precancerous oral lesions,
such as leukoplakia or lichen planus, while 35.3%
had or used to have a tobacco addiction and
17.64% were regular alcohol consumers. In those
cases considered for this review, OSCC developed very close to or directly in contact with the
dental implants. In most of the cases, at the time
of implant placement, there were 1 or more risk
factors for the development of oral carcinoma.
Block and Scheufler in 2001 presented the
case of a man aged 72, referred for the treatment
of a progressive bone loss of 5 years of evolution
surrounding 2 implants.14 This patient had
proper oral hygiene and was a former smoker,
having quit 16 years before, and had had a verrucous carcinoma removed from the alveolar
bone of the lower jaw 3 years earlier. He had not
undergone chemotherapy or radiotherapy. Two
years later, after checking that the patient was
in total remission, 2 implants had been placed
in the left posterior region of his mandible. Six
months later, the verrucous carcinoma reappeared on the periimplant mucosa. All of the
affected tissue was removed, and a year later, 5
more implants were placed in order to support
a fixed complete prosthesis. Five months after
the placement of these implants, bone loss compatible with periimplantitis was found around 2
of the implants, with gingival hyperplasia and
suppuration. After performing a biopsy, a welldifferentiated OSCC was diagnosed. The 2
38 Volume 4 | Issue 4/2018

affected implants were removed, and after 18
months of follow-up, the patient was free of
cancer and wore a removable prosthesis retained
on the remaining implants.
Czerninski et al. in 2006 reported a case
series in which implants were placed to replace
missing teeth and ulcers appeared around these
implants after several years after treatment.15
Histological analysis of these lesions confirmed
the presence of OSCC surrounding the implants.
The first case was of a 52-year-old woman, a
smoker for more than 20 years, referred for
treatment of oral lichen planus 8 years before.
She had 3 implants, which had been placed
3 years before, and presented with a reddened
mucosa surrounding the implants with ulcers of
up to 25 mm on the alveolar ridge, initially diagnosed as periimplantitis. Radiographic examination showed bone loss surrounding the implants
and a biopsy was done on which superficially
invasive OSCC was diagnosed. Mandibulectomy
and lymphatic node dissection were performed.
After 18 months of follow-up, the patient was
still free of cancer.
The second case was of an 80-year-old man
with a history of diabetes and chronic ischemic
heart disease. This patient had previously been
treated for OSCC by resection, with no radiotherapy or combined treatment. On clinical
examination, the patient had 5 dental implants,
which had been placed 5 years earlier, in the
anterior region of the mandible and presented
with a partly ulcerated exophytic mass surrounding the implants of around 15 mm in diameter. The radiograph showed an osteolytic lesion
with nondefined edges located lateral to the
implants on the right of the patient’s mouth.
Histological analysis confirmed OSCC affecting
the mucosa and bone. This patient chose local
extirpation of the tumor combined with palliative treatment and died a few months later
because of cancer.15
In 2008, Eguia del Valle et al. published the
case of a man of 76 years of age who wore a fixed
prosthesis supported on 2 implants located in
the mandibular right region.16 No toxic habits
were present, and his general health was good.
Three years after the implant placement, the
patient presented with a white exophytic lesion
of 6 mm in diameter and with superficial ulceration, located on the surrounding tissue of 1 of
the implants. Radiographic examination showed
cone-shaped bone loss surrounding this implant,
and the biopsy confirmed the presence of a
well-differentiated OSCC. Total resection of the

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[39] =>
Oral cancer and dental implants

tumor was performed, as well as lymphatic node
dissection, but metastasis was not found.
Kwok et al. described in 2008 3 cases of
OSCC in patients of 62, 71 and 67 years of age.17
All of them previously had risk factors for the
development of oral cancer prior to the implant
placement (previous oral carcinoma, previous
breast cancer, smoking and alcohol use.
Gallego et al. published in 2009 a case of a
70-year-old woman who wore an overdenture
supported on 3 dental implants.18 Her medical
history provided no data of interest. The patient
had an ulcerated lesion of 1 month of evolution
located where the bar of the prosthesis pressed
on the mucosa, close to 1 of the 3 implants.
Biopsy confirmed a diagnosis of OSCC, requiring
immediate removal of the bar and resection of
part of the mandible. One year later, the patient
was free of disease.
In 2009, Gulati et al. described the case of
a female patient of 62 years of age and a heavy
smoker (more than 20 cigarettes per day) who
had been referred owing to a white lesion on
the alveolar ridge at the mandibular left first
molar. 19 Biopsy confirmed a diagnosis of
well-differentiated OSCC, and a hemimandibulectomy was performed, plus radical dissection of neck nodes. One year later, implants
were placed, but during the following 7 years,
the patient suffered several episodes of periimplantitis of some of her implants. Several biopsies were done, all of them showed unspecific
chronic inflammation, but no signs of dysplasia.
However, 1 year later, another biopsy showed
the presence of OSCC spread to the mouth floor.
The treatment was radical dissection of the
affected area, and 12 months later, 3 dental
implants were placed in the anterior region.
Again, 1 year after the implant placement,
periimplantitis appeared again and biopsy confirmed the recurrence of the OSCC. Finally, the
patient died because of other metastases.
The largest series of cases was published by
De Ceulaer et al. in 2010.20 Twenty-one patients
were operated on with OSCC resection, and
afterward implants were placed. In total, the
patients had 56 implants placed. Sixteen of the
patients had their implants placed in the same
tumor resection surgery, and 5 of them in a
second surgery. All of them underwent the same
radiotherapy protocol. The results show that, in
the group of implants placed in the same surgery, 3 patients had a tumor recurrence surrounding an implant; however, no recurrences
were reported in the 2-stage surgery group.

Meijer et al. in 2010 reported the clinical case
of a 69-year-old female patient with an overdenture on 2 mandibular anterior implants.21 Eight
years earlier, she had been operated on for resection of OSCC on the floor of the mouth, and in
the same operation, several implants were
placed to rehabilitate the area. Radiotherapy was
necessary, and 3 months post-irradiation, prosthetic rehabilitation was performed. Four years
after the prosthetic rehabilitation, a new tumor
was detected around the adjacent keratinized
tissue of both implants. Radiographically, there
were no signs of osteolysis, and a partial mandibulectomy with the removal of both implants
was performed. After 2 years, new implants
were placed, and the patient was free of disease
1 year later.
Agostini et al. in 2011 reported a case that
they referred to as periimplant squamous carcinoma.22 The person affected was a 64-year-old
male patient with 3 implants in the mandibular
left quadrant. Two months after placement, a
painful radiolucency appeared close to the
second premolar. A week later, there was a spontaneous failure of the implant and the pain had
spread to the other 2. After the biopsy, OSCC
was identified, and the corresponding resection
carried out. After 7 years of follow-up, the
patient showed no signs of recurrence.
Jané-Salas et al. in 2012 presented 2 cases.
The first was of a 42-year-old male with a history
of morbid obesity, but without toxic habits, who
had had implants since 2007 in the mandibular
posterior region.23 The patient had no prosthesis
on the implants and was examined owing to the
presence of a painless ulcer or bleeding at the
right edge of the tongue, which he attributed to
self-injury and for which he refused a biopsy. In
2009, the ulcer persisted, and after the biopsy,
OSCC was found. Hemimandibulectomy with
lymphatic node resection was performed, and
6 months later, there was no evidence of recurrence of the lesion. The second case was of a
79-year-old man with no relevant history or toxic
habits who had worn a complete maxillary
denture on 7 implants for 9 years. The patient
came to be examined because of the presence
of an ulcer on the side of the tongue suspected
to have arisen from trauma due to the fracture
of ceramics of their maxillary rehabilitation.
After 8 days, the ulcer had improved considerably, although soon after a biopsy of the ulcer,
which was still present, the diagnosis of OSCC
was confirmed. The patient underwent hemiglossectomy and functional dissection of

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[40] =>
Oral cancer and dental implants

Study

Age/Sex

No.
of DIs

Localization
of tumor

Medical
history

Block &
Scheufler14

72/
Male

8

Mandibular left posterior

Verrucous carcinoma of mandibular
left alveolar ridge (1 recurrence)

52/
Female

3

Mandibular left posterior

Hypothyroidism, chronic hives

80/
Male

5

Mandibular left posterior,
mandibular anterior

OSCC, colon carcinoma, DM II,
ischemic heart disease

76/
Male

2

Mandibular right posterior

Hyperuricemia, HBP,
ventricular arrythmia

62/
Male

14

Mandibular right posterior

Not relevant

71/
Male

2

Mandibular left posterior

Not relevant

67/
Female

2

Mandibular left posterior

No data

Gallego et al.18

70/
Female

3

Mandibular left posterior

Not relevant

Gulati et al.19

62/
Female

5

Mandibular left posterior,
mandibular anterior

OSCC in mandible

77/
Female

2

Mandibular right posterior

OSCC on floor of mouth

71/
Male

2

Mandibular right posterior

OSCC on floor of mouth

62/
Female

5

Mandibular left posterior

OSCC on floor of mouth

Meijer et al.21

69/
Female

2

Mandibular anterior

OSCC on floor of mouth

Agostini
et al.22

64/
Male

3

Mandibular right posterior

Not relevant

42/
Male

4

Right side of tongue

Obesity, hypothyroidism

79/
Male

12

Left side of tongue

Not relevant

55/
Female

4

Mandibular anterior

Lung carcinoma,
pancreatic carcinoma

Czerninski et al.15

Eguia del Valle et al.16

Kwok et al.17

De Ceulaer et al.20

Jané-Salaset al.23

Pfammatteret al.24

DI = dental implant; T = time from implant placement to OSCC diagnosis; DM II = diabetes mellitus type II; HBP = high blood pressure; rx = radiographic examination.

40 Volume 4 | Issue 4/2018

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Oral cancer and dental implants

T
(months)

Clinical
appearance

Suspected
diagnosis

15

Alveolar bone loss,
gingival hyperplasia, pain,
suppuration

Periimplantitis

Oral lichen planus

46

25 mm ulcer after DIs,
exophytic mass lingual to DIs,
reddened mucosa. Rx: bone
loss surrounding DIs

Periimplantitis

Previous carcinoma

60

Ulcerated exophytic mass
of 15 mm surrounding DI,
osteolytic lesion

Periimplantitis

None

36

White ulcerated exophytic
lesion of 6 mm beside DI,
chronic bone loss
surrounding DI

Periimplantitis

Ex-smoker, alcohol use

3

Periimplant ulcerated lesion

Not mentioned

Ex-smoker, alcohol use

72

Inflammatory changes
surrounding DI

Periimplantitis

OSCC, breast carcinoma,
ex-smoker, alcohol use

12

Granulation area
surrounding DI

Not mentioned

None

120

Chronic ulcerated lesion
due to trauma

Traumatic ulcer

96

Periimplantitis episodes,
with biopsies over
7 years showing chronic
inflammation

Periimplantitis

Previous carcinoma

24

Reddened periimplant
mucosa, pain, suppuration,
bone loss surrounding DI

Periimplantitis

Previous carcinoma

7

Mucosal inflammation
surrounding DI

Periimplantitis

Previous carcinoma

6

Pain and inflammation
surrounding DI

Periimplantitis

Previous carcinoma

48

Exophytic mass surrounding
2 DIs. Rx: no osteolysis

Not mentioned

None

10

Periimplant squamous
carcinoma

Not mentioned

24

Nonpainful lesion, no
bleeding, right side of tongue,
contacting DI

Self-injury

None

Ulcerated lesion,
left side of tongue

Traumatic origin lesion

None

Reddened periimplant
mucosa, pain,
suppuration, 2–3 mm bone
loss surrounding DI

Periimplantitis

Risk factors

Previous carcinoma,
oral leukoplakia, ex-smoker

Previous carcinoma, smoker

Ex-smoker

12

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Volume 4 | Issue 4/2018 41

Table 1
Clinical cases from the articles
included in this review.


[42] =>
Oral cancer and dental implants

lymphatic nodes. The patient remained free of
disease after 2 years of follow-up.
Pfammatter et al. in 2012 presented the case
of a 55 -year-old woman with a history of
pancreatic carcinoma who was referred by her
dentist during chemotherapy owing to periimplantitis around an implant in the mandibular
right anterior region.24 The mucosa showed a
smooth surface and typical signs of inflammation: pain, suppuration, erythema and a periodontal probing depth of 7 mm. Radiographic
analysis showed distal and mesial bone loss of
2–3 mm around the implants in the mandibular
anterior area. The area was mechanically
debrided, and chlorhexidine and metronidazole
gel were applied locally. Clinical signs decreased
in the following 2 weeks, but 3 weeks later, the
pain and suppuration appeared again and paresthesia of the lower lip was observed by the
patient. Biopsy was performed in the implant
area, revealing OSCC. The patient died 4 weeks
after diagnosis.
Javed et al. in 2012 included in their review
a total of 14 studies. Nine of these had a previous
history of cancer, and 5 had toxic habits (tobacco
and/or alcohol use).25

Discussion
Numerous studies have shown that dental
implants can osseointegrate and remain functionally stable for long periods, both in healthy
individuals and in medically compromised
patients, including those who have undergone
oncological therapy.6–11 However, although the
evidence demonstrates the success of implant
treatment in terms of survival,8, 10, 12 it is also true
that there are numerous cases in the literature
in which OSCC has been diagnosed around
dental implants.14–25 Because of the multiple
factors involved in the carcinogenesis process,
it is very difficult to prove whether this relationship is purely coincidental or not.
Considering the cases evaluated in this
review, several questions with difficult responses
arise from current evidence: What exactly is the
role of dental implants in the development of
OSCC? And is it appropriate to treat a patient
with implants if he or she has a previous history
of carcinoma, premalignant lesions or another
risk factor? Do implants alone increase the risk
of the patient developing oral cancer?
OSCC around dental implants may present
as a hyperplasic and/or ulcerated red zone of oral
42 Volume 4 | Issue 4/2018

mucosa with alveolar bone loss, and is sometimes not distinguishable from periimplantitis
when it develops around a prosthetic rehabilitation with dental implants, thereby presenting
a possibility of misdiagnosis. Periimplantitis is a
complication of implant treatment and typically
shows alveolar bone loss around the affected
implants, in addition to inflammation of the
periimplant soft tissue.13 Since such inflammatory lesions around implants may manifest clinical and radiographic similarities to malignant
diseases, in the case of gingival hyperplasia and/
or bone resorption around an implant, it is necessary to perform a thorough differential diagnosis. Under these circumstances, it is necessary
to perform a detailed clinical and radiographic
evaluation, accompanied by a biopsy and a histopathological test.
Thus, Block and Scheufler presented the
case of a patient with periodontal bone loss
around implants that initially was diagnosed as
periimplantitis.14 The periimplant tissue that
occupied the area of bone loss was debrided and
sent for microscopic evaluation, and the histological results showed the presence of a well-differentiated OSCC.23 The authors suggest that
the likely sequence of OSCC development was
from the soft tissue into the bone through the
implants. The tumor had arisen in the soft tissue,
and the implants had created a similar environment to the periodontal sulcus, facilitating the
progression to bone.
A review of the literature from 1980–200515
found 4 articles describing 6 cases of OSCC
associated with dental implants, which together
with the 2 cases that the research group documented, brought the number to 8 cases. The
mean age (72 years; range: 52–90 years) of the
sample was higher than that of the present study
(mean age: 66.3 ± 10.1 years), with a similar sex
distribution. The location of the tumor was the
lower jaw in all of the cases and only 1 of them
had extension to the floor of the mouth. In the
present review, there was also a clear predominance of mandibular occurrence (88.23%), particularly in the mandibular posterior area
( 76 . 46 %) and mandibular anterior region
(11.77 %). Only in 2 out of the 17 cases did the
tumor appear at the side of the tongue.
The etiology of OSCC is multifactorial, and it
includes factors related to age, a previous history
of oral and/or systemic cancer, toxic habits
(tobacco and/or alcohol use) and infection with
the human papillomavirus.4, 5 Nutrition (diet high
in fats and low in fruits and vegetables) and

Journal of
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[43] =>
Oral cancer and dental implants

hygiene (poor oral hygiene) factors are also associated with an increased risk of oral cancer. 4
Although OSCC may appear directly, it is usually
preceded by premalignant oral lesions such as
leukoplakia, erythroplakia or lichen planus. 4
Czerninski et al. found that 87.5% of the evaluated patients had risk factors for developing oral
carcinoma (a previous history of cancer [50.0%],
premalignant lesions [25.0%] and toxic habits
[25.0%]).15 The time between implant placement
and tumor diagnosis varied from 0.5 years to 13
years (median: 4.5 years). Similar data were
obtained in the present review, in which 76.47%
of the patients had 1 or more risk factors for
malignancy prior to placement of the dental
implants, 47.06% of the cases had a history of
oral carcinoma (OSCC and verrucous carcinoma
of the alveolar ridge) or systemic cancer in other
organs far from the oral cavity (lung cancer, pancreatic and breast), 11.76% had premalignant oral
lesions (leukoplakia or lichen planus), 35.3% had
or had had a smoking habit, and 17.64% were
regular alcohol consumers. The average time
between placement of the implants and diagnosis of OSCC in this review ranged between
0.25 months and 120 months (mean: 42 months).
Smoking is the major known risk factor for the
development of both premalignant oral lesions
and oral cancer. It also has a negative effect on
long-term implant success, as smoking cessation
has shown significantly better outcomes.26 There
are reported cases in which the patient had no
identified risk factor for developing oral carcinoma, and in all of them, the tumor was developed in close contact with the implants.18, 22, 23
Some authors consider chronic trauma as resulting in a precancerous lesion if the cause of the
trauma is not properly addressed.18, 27
In all of the cases described but 1,21 the tumor
spread quickly into the bone and radiographic
evidence of bone loss around the implant was
found. OSCC begins in soft tissue and tends to
invade the bone.2, 3
De Ceulaer et al. concluded that there is a
higher recurrence of oral carcinoma in cases in
which implants are placed in the same surgical
procedure in which the tumor is removed.20 They
stated therefore that it would be advisable to
wait for a second stage for implant placement
once the tissue has healed and become stable.20
It is suggested that good periodontal health
could provide a natural barrier against tumor
progression, delaying bone infiltration.16 Otherwise, the implant could provide an environment
conducive to the rapid progression of the tumor

to the bone in those cases in which the cancer
originated in the epithelium of the adjacent
mucosa.
In those cases in which the decision to place
implants in a patient at high risk of developing
oral carcinoma (smoking and a previous history
of a tumor and/or premalignant lesion) is made,
careful monitoring and appropriate clinical and
radiographic follow-up will be indicated. The
prosthesis should be designed to facilitate easy
and regular removal, allowing regular control of
the tissue.18

Conclusion
In relation to the published evidence, definitive
conclusions cannot be reached, although it can
be said that, in patients with risk factors for oral
carcinoma, an appropriate individualized risk–
benefit assessment should be considered before
making the decision to place implants.
In patients with risk factors who have been
treated with dental implants, regular clinical and
radiographic examination will be extremely necessary. The prosthesis should be designed to
permit removal of plaque and facilitate adequate
examination of the tissue. In the case of inflammatory changes or any kind of periimplant
lesion, a biopsy should be taken and histopathologically analyzed urgently. In cases of patients
who have developed an oral carcinoma, if
implant placement is decided on, the surgery
should be performed in a second phase, and not
in the same tumor resection surgery, because a
higher number of recurrences have been
recorded for the latter.
Further studies are needed with larger series
of cases and in collaboration with various cancer
centers in order to explore further any direct
relationship between OSCC and dental implants,
as well as the possible role of the risk factors
involved.

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

Journal of
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Oral cancer and dental implants

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Ferlay J, Shin HR, Bray F, Formah D,
Mathers C, Parkin DM. Estimates of
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Johnson NW, Jayasekara P, Amarasinghe
AA. Squamous cell carcinoma
and precursor lesions of the oral cavity:
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Rothenberg SM, Ellisen LW. The molecular
pathogenesis of head and neck squamous
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Hirota SK, Braga FP, Penha SS, Sugaya
NN, Migliari DA. Risk factors for oral
squamous cell carcinoma in young and
older Brazilian patients: a comparative
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Liang C, Marsit CJ, McClean MD, Nelson
HH, Christensen BC, Haddad RI, Clark JR,
Wein RO, Grillone GA, Houseman EA,
Halec G, Waterboer T, Pawlita M, Krane
JF, Kelsey KT. Biomarkers of HPV in
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Buser D, Janner SF, Wittneben JG,
Brägger U, Ramseier CA, Salvi GE.
10-year survival and success rates of 511
titanium implants with a sandblasted
and acid-etched surface: a retrospective
study in 303 partially edentulous
patients.
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2012 Dec;14(6):839–51.

7.
Jiang BQ, Lan J, Huang HY, Liang J, Ma
XN, Huo LD, Xu X. A clinical study on
the effectiveness of implant supported
dental restoration in patients
with chronic periodontal diseases.
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2013 Feb;42(2):256–9. doi:10.1016/j.
ijom.2012.08.001. Epub 2012 Sep 26.
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Javed F, Al-Hezaimi K, Al-Rasheed A,
Almas K, Romanos GE. Implant survival
rate after oral cancer therapy: a review.
→ Oral Oncol.
2010 Dec;46(12):854–9.
9.
Bianchi B, Ferri A, Ferrari S, Leporati M,
Copelli C, Ferri T, Sesenna E. Mandibular
resection and reconstruction in the
management of extensive ameloblastoma.
→ J Oral Maxillofac Surg.
2013 Mar;71(3):528–37. doi:10.1016/j.
joms.2012.07.004. Epub 2012 Sep 27.
10.
Jacobsen C, Kruse A, Lübbers HT,
Zwahlen R, Studer S, Zemann W, Seifert
B, Grätz KW. Is mandibular reconstruction using vascularized fibula flaps and
dental implants a reasonable treatment?
→ Clin Implant Dent Relat Res.
2014 Jun;16(3):419–28. doi:10.1111/
cid.12004. Epub 2012 Sep 21.
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Anne-Gaëlle B, Samuel S, Julie B, Renaud L,
Pierre B. Dental implant placement after
mandibular reconstruction by
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2011 Dec;47(12):1099–104.
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Carbiner R, Jerjes W, Shakib K,
Giannoudis PV, Hopper C. Analysis of the
compatibility of dental implant
systems in fibula free flap reconstruction.
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2012 Jun 21;4:37.
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Lindhe J, Meyle J; Group D of European
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Peri-implant diseases: consensus report
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→ J Clin Periodontol.
2008 Sep;35(8 Suppl):282–5.

44 Volume 4 | Issue 4/2018

14.
Block MS, Scheufler E. Squamous cell
carcinoma appearing as peri-implant
bone loss: a case report.
→ J Oral Maxillofac Surg.
2001 Nov;59(11):1349–52.
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Czerninski R, Kaplan I, Almoznino G, Maly
A, Regev E. Oral squamous cell
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2006 Oct;37(9):707–11.
16.
Eguia del Valle A, Martínez-Conde
Llamosas R, López Vicente J, Uribarri
Etxebarria A, Aguirre Urizar JM. Primary
oral squamous cell carcinoma arising
around dental osseointegrated implants
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2008 Aug 1;13(8):E489–91.
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Kwok J, Eyeson J, Thompson I, McGurk
M. Dental implants and squamous cell
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three cases.
→ Br Dent J.
2008 Nov;205(10):543–5.
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Gallego L, Junquera L, Llorente S.
Oral carcinoma associated with
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→ Dent Traumatol.
2009 Feb;25(1):e3–4.
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Gulati A, Puthussery FJ, Downie IP, Flood
TR. Squamous cell carcinoma presenting
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→ Ann R Coll Surg Engl.
2009 Oct;91(7):W8–10.
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De Ceulaer J, Magremanne M, van Veen
A, Scheerlinck J. Squamous cell
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2010 Oct;68(10):2507–12.

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Meijer GJ, Dieleman FJ, Bergé SJ, Merkx
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mandibulectomy. A case report.
→ Oral Maxillofac Surg.
2010 Dec;14(4):253–6.
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Agostini T, Sacco R, Bertolai R, Acocella
A, Colafranceschi M, Lazzeri D.
Peri-implant squamous odontogenic
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→ J Craniofac Surg.
2011 May;22(3):1151–7.
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Jané-Salas E, López-López J, RosellóLlabrés X, Rodríguez-Argueta OF,
Chimenos-Küstner E. Relationship
between oral cancer and implants:
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review.
→ Med Oral Patol Oral Cir Bucal.
2012 Jan 1;17(1):e23–8.
24.
Pfammatter C, Lindenmüller IH, Lugli A,
Filippi A, Kühl S. Metastases and primary
tumors around dental implants:
a literature review and case report of
peri-implant pulmonary metastasis.
→ Quintessence Int.
2012 Jul–Aug;43(7):563–70.
25.
Javed F, Al-Askar M, Qayyum F, Wang
HL, Al-Hezaimi K. Oral squamous cell
carcinoma arising around osseointegrated dental implants.
→ Implant Dent.
2012 Aug;21(4):280–6.
26.
Liddelow G, Klineberg I. Patient-related
risk factors for implant therapy.
A critique of pertinent literature.
→ Aust Dent J.
2011 Dec;56(4):417–26.
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→ J Oral Pathol Med.
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[46] =>
PTFE strips as adjuvant in apical surgery

The effect of autoclavable
polytetrafluoroethylene strips
as adjuvant to hemostatic
material in periapical surgery:
A technical note
Abstract
Purpose
Guillermo Cabanes Gumbau,a David Soto Peñaloza,a
Juan Cervera Ballester,a David Peñarrocha Oltraa
& Miguel Peñarrocha Diagoa
a

Oral Surgery Unit, Department of Stomatology, Faculty
of Medicine and Dentistry, University of Valencia,
Valencia, Spain

Corresponding author:

An adequate hemostasis is of utmost importance for the success of apical
surgery, because it not only improves operative visibility, but also provides a dry environment within the bony crypt, ideal for an adequate
retrograde obturation. This article describes a new approach for the
successful management of hemostasis during apical surgery through
the use of autoclavable polytetrafluoroethylene (PTFE) strips as an
adjunct to epinephrine-impregnated gauze as the hemostatic material.
Materials and methods

Dr. David Soto Peñaloza
Universitat de València
Clínica Odontológica
Unidad de Cirugía Bucal
Gascó Oliag 1
46021 Valencia
Spain

The treatment protocol entailed the application of PTFE strips as an
adjunct to epinephrine-impregnated gauze in the apical microsurgery
approach, using mineral trioxide aggregate as retrograde obturation
material and advanced platelet-rich fibrin plus (A-PRF+) membranes as
filling material of the bony crypt.

dr.davidsotpe@gmail.com
How to cite this article:
Cabanes Gumbau G, Soto Peñaloza D, Cervera Ballester
J, Peñarrocha Oltra D, Peñarrocha Diago M.
The effect of autoclavable polytetrafluoroethylene strips
as adjuvant to hemostatic material in periapical surgery:
A technical note.
J Oral Science Rehabilitation. 2018 Dec;4(4):46–51.

Results

A synergistic effect of the application of PTFE strips adjunct to epinephrine-impregnated gauze was found, yielding good intraoperative visualization and hemostasis. PTFE strips work as a mechanical barrier, and
the material is easily adapted to the bony crypt size and feature by compression. Moreover, PTFE strips are easy to remove without leaving residues that may impair healing.
Conclusion

PTFE strips and epinephrine-impregnated gauze demonstrated a good
synergistic effect on hemostasis. PTFE strips are a simple, innocuous
and cheap means of enhancing bleeding control during apical surgery.
Keywords

Apical surgery; PTFE; hemostatic agent; oral surgery; advanced plateletrich fibrin plus.
46 Volume 4 | Issue 4/2018

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PTFE strips as adjuvant in apical surgery

Introduction
The use of an adequate hemostatic agent is considered of utmost importance among factors
related to clinical success in apical surgery.
Bleeding control improves vision at the surgical
site, reducing operating time, and preventing
hemorrhage and postoperative swelling.1 Different techniques and materials have been used to
control hemostasis in apical surgery, the most
used being bone wax, collagen membranes, ferric
sulfate, epinephrine and aluminum chloride.
Kim and Rethnam in 1997 described that a
good hemostatic agent should stop the hemorrhage in a short period, be easy to handle, be
biocompatible, be relatively cheap and secure,
and not complicate or delay the wound healing.2
An optimal surgical dry environment is necessary to achieve the best results regarding material properties during retrograde obturation (e.g.,
MTA, Biodentine and super EBA). Nowadays, the
search for an ideal hemostatic agent continues,
and different agents (e.g., calcium sulphate,
ferric sulphate, collagen plus epinephrine, and
aluminum chloride-based paste Expasyl) have
been tested and documented in clinical studies.3
A recent adequate sample size clinical trial
demonstrated the superiority in terms of bleeding control of aluminum chloride-based paste
Expasyl over a gauze impregnated with epinephrine, but without statistically significant differences. Nevertheless, to date, there is no consensus about which of them is the best option. 4
Moreover, translational evidence suggests that
Expasyl plus ferric sulphate or electrocauterization are superior regarding bleeding control
compared with other hemostatic agents in
rabbit calvaria. 5 However, they were accompanied by unfavorable tissue reactions, such as
necrotic bone, presence of inflammatory cells
and absence of bone repair. 5 To reduce these
effects, it has been suggested that bone defects
should be freshened with a rotary instrument
before suturing.
Several hemostatic agents are liquids (e.g.,
epinephrine and ferric sulphate) and carriers are
used for their delivery (e.g., resorbable collagen
sponges and cotton pellets).6 The ideal carrier
material should be able to be removed without
leaving traces that impair healing.
Polytetrafluoroethylene (PTFE) or plumber’s
tape is used for multiple applications in dentistry
because it is a nonstick, inert and pliable
material.7 In dental implant-supported prosthodontics, it is used like a sealer material for

implant abutment screw holes,8 minimizing the
risk of screw head damage during retrieval procedures. 7 PTFE is nonfilamentous and thus
easier to remove compared with cotton pellets,
which tear easily during removal. PTFE tape is
also used as a spacer beneath temporary restorative obturation material in root canal therapy,
yielding less bacterial leakage.9
PTFE strips can be compacted against the
walls of the bony crypt after ostectomy. The
material can be adapted to the defect size and
through compression works as a mechanical
hemostatic barrier. Hence, the present article
was aimed at introducing a novel approach to
managing the bleeding during periapical surgery,
through the use of PTFE strips as a mechanical
hemostatic material adjunct to epinephrineimpregnated gauze.

Technical report and clinical case
A brief description of the periapical surgery
technique is first given to depict the use of PTFE
strips as an adjunct for establishing hemostasis,
based on a clinical case and its postoperative
care. The case is detailed thereafter.

Materials and methods
The surgery was carried out under local anesthesia with 4% articaine and 1:100,000 epinephrine (Inibsa). The flap approach entailed making
a paramarginal incision. Once the flap had been
elevated, the inflammatory tissue surrounding
the root apex, forming a bone crypt, was
debrided using manual curettes. Hemostasis
was achieved using epinephrine-impregnated
gauze, subsequently reinforced with PTFE strips
previously sterilized by autoclave, and compacted using an amalgam ball burnisher-plugger
within the bony crypt surrounding the tooth
apex. The root ends were inspected using a rigid
endoscope (Möller-Wedel). The root-end cavities
were prepared with sonic-driven microtips and
ultrasonic tips (Piezon Master 400, EMS Electro
Medical Systems), and then were retrofilled with
mineral trioxide aggregate (MTA; Dentsply Tulsa
Dental Specialties). Finally, the quality of the
retrograde fillings was inspected using a rigid
endoscope (Möller-Wedel).
The bony crypts were regenerated using an
autologous platelet concentrate. Membranes of
advanced platelet-rich fibrin plus (A-PRF+;

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PTFE strips as adjuvant in apical surgery

Fig. 1

Fig. 1
Intraoral view. Maxillary
anterior region without
swelling or pathological signs.
Fig. 2
Periapical radiograph of the
anterior incisors that had
undergone root canal therapy.
Apical radiolucencies can be
observed surrounding the root
apices.
Fig. 2

Figs. 3A &B
CBCT images.
(A) Panoramic view of the
maxilla, where apical lesions
can be more clearly seen
around the incisal apices.
(B) The CBCT sagittal slice
confirmed that the apical
defects were related to the
root canal retreatment.

Figs. 3 A & B

A

B

Process for PRF, Nice, France) were prepared
from the patient’s venous blood, collected in
3 × 10 mL sterile glass vacuum tubes (plain
vacuum tube A-PRF™+; Process for PRF, Nice,
France) and centrifuged at 1,300 rpm × 8 min
(200 × g). This process allows one to obtain a
3-D fibrin mesh enriched with platelets, and
growth factor released from platelet alpha
granules after a slow activation without additives. This mean of production provides a source
of biological signals and growth factors that
enhances wound repair and angiogenesis.10–12

Clinical case
A 57-year-old female patient was referred to
our clinic because of an asymptomatic apical
lesion involving single-rooted teeth in the anterior maxilla. The patient reported no relevant
systemic condition or allergies. The clinical
exploration found good oral hygiene and periodontal status. The patient reported that she
smoked 11–15 cigarettes per day, and no softtissue alterations in the region of interest were
observed (Fig. 1). In an intraoral radiograph, the
2 central incisors and 1 lateral incisor that had
undergone root canal therapy showed apical
48 Volume 4 | Issue 4/2018

radiolucencies surrounding the root apices. One
central incisor showed a previous periapical
surgery (Fig. 2). The CBCT study confirmed that
not only the central but also the contiguous
lateral and central incisors were affected, as
verified in the panoramic view and sagittal
slices (Fig. 3). No pathological periodontal pockets were present but a slight gingival recession
in the buccal side was present, of type I according to Miller.13
A paramarginal incision was performed to
reach the affected area, and a full-thickness surgical flap was raised at the buccal side, followed
by ostectomy and apicoectomy (Fig. 4). Hemostasis was then performed using epinephrineimpregnated gauze and PTFE strips, and the
retrograde cavity was prepared and sealed with
MTA (Fig. 5). Excess material was removed with
manual curettes and rotary instruments (Fig. 6).
The root integrity and apical filling were ascertained using a rigid endoscope (Fig. 7).
The bony defects of the affected apical areas
were filled with pieces of A-PRF+ membranes
(Fig. 8). After cleaning the intervention area with
saline solution, primary wound closure was
accomplished with multiple interrupted sutures
(Fig. 9). A postoperative periapical radiograph
was taken (Fig. 10).

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PTFE strips as adjuvant in apical surgery

Fig. 4

Figs. 7A–F

A

Fig. 5

Fig. 6

D
Fig. 4
Buccal lesions were accessed
through a paramarginal flap.
The apical lesions were
accessed after osteotomy and
granulation tissue debridement.

B

E

C

F

Fig. 5
Bony crypt bleeding was
controlled by applying
epinephrine-impregnated
gauze and PTFE strips
packaged with pressure
against the bony walls.
The cavity preparation was
done using an ultrasonic
tip, then MTA filling material
was used to obturate
the retrograde cavity. Good
bleeding control can be
observed.
Fig. 6
MTA excess was removed
using a surgical curette.

Figs. 8A & B

A

Fig. 7
Rigid endoscopic images.
Apical preparation and root
canal integrity were
ascertained.
(A–C) Retrograde obturation
quality was inspected.
(D–F) The good bleeding
control can be appreciated.

B

Figs. 8A & B
Regenerative procedure with
platelet concentrate.
(A) Before flap repositioning,
the bony crypt was filled with
pieces of autologous fibrin
matrix, A-PRF+ membrane.
(B) A-PRF+ membranes were
placed inside the apical bony
crypts.

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PTFE strips as adjuvant in apical surgery

Fig. 9

Fig. 10

Fig. 9
Flap suturing with
resorbable material.
Fig. 10
Postoperative periapical
radiograph.

Postoperative care
The patient was prescribed amoxicillin
(500 mg/8 h) for 5 days after the intervention,
ibuprofen (400 mg/8 h) for 4 days, a 0.12% chlorhexidine rinse (twice a day) for 7 days, and paracetamol (500 mg on demand) in the event of Expasyl + Stasis and electrocautery.16 However,
intense pain. The sutures were removed after this bleeding control efficacy was accompanied
1 week.
by unfavorable tissue reactions, such as necrotic
bone, inflammatory cells and the absence of
bone repair.5 Using impregnated gauze with epiDiscussion
nephrine showed good hemostatic results, but
inferior to those obtained with Expasyl. 4 The
Achieving success in apical surgery requires advantage of this method is that it does not leave
adequate bleeding control to reduce the surgery residues that might affect wound healing after
time, enhance operative vision and diminish apical surgery.
postoperative complications such as swelling
Available evidence is not conclusive regardand patient discomfort. Most importantly, it ing the best hemostatic agent, but denotes that
allows us to guarantee optimal conditions for being cheap and easy to handle are among the
the setting of the retrograde sealing material. desirable characteristics. 2 PTFE tape is cheap,
Hemostatic agents and materials by defini- easy to handle and to remove from the bony
tion are classified according to their properties. crypt, leaving no residues, and autoclavable.
They can be chemical or mechanical, working as For the above-mentioned reasons, we tested
a barrier, such as bone wax. Bone wax has been sterilized PTFE strips as a new means of
used for many years and is easy to handle, enhancing the already good bleeding control
though remaining traces of this material can usually achieved with epinephrine-impregnated
cause adverse tissue reactions.14 Similar prob- gauze.
lems have been observed with ferric sulfate:
The use of PTFE strips combined with
When not completely eliminated from the sur- epinephrine-impregnated gauze might provide
gical site, it gives rise to foreign-body reactions bleeding control comparable to that of Expasyl
that complicate healing.15
without the drawbacks of this method, diffiThe hemostatic efficacy and the tissue reac- culty of removal and risk of postoperative
tions of bone wax, ferric sulfate, aluminum chlo- tissue reactions.
ride, and a combination of aluminum chloride
and ferric sulfate were assessed previously by
Conclusion
16
an experimental report. The authors indicated
that Expasyl alone or in combination with ferric PTFE strips and epinephrine-impregnated gauze
sulfate was the most effective agent.16 Another demonstrated a good synergistic effect on
study compared 5 hemostatic techniques fol- hemostasis. PTFE strips are a simple, innocuous
lowing the same preclinical design reported by and cheap means of enhancing bleeding control
von Arx et al. in 2006 and found that the most during apical surgery. Clinical studies should be
effective methods for reducing bleeding were done to evaluate this technique.
50 Volume 4 | Issue 4/2018

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PTFE strips as adjuvant in apical surgery

References
1.
Witherspoon DE, Gutmann JL.
Haemostasis in periradicular surgery.
→ Int Endod J.
1996 May;29(3):135–49.
2.
Kim S, Rethnam S. Hemostasis
in endodontic microsurgery.
→ Dent Clin North Am.
1997 Jul;41(3):499–511.
3.
Clé-Ovejero A, Valmaseda-Castellón E.
Haemostatic agents in apical surgery.
A systematic review.
→ Med Oral Patol Oral Cir Bucal.
2016 Sep;21(5):e652–7.
doi:10.4317/medoral.21109.
4.
Menéndez-Nieto I, Cervera-Ballester J,
Maestre-Ferrín L, Blaya-Tárraga JA,
Peñarrocha-Oltra D, Peñarrocha-Diago
M. Hemostatic agents in periapical
surgery: a randomized study of gauze
impregnated in epinephrine versus
aluminum chloride.
→ J Endod.
2016 Nov;42(11):1583–7. doi:10.1016/j.
joen.2016.08.005.
5.
Jensen SS, Yazdi PM, Hjørting-Hansen E,
Bosshardt DD, Von Arx T. Haemostatic
effect and tissue reactions of methods
and agents used for haemorrhage control
in apical surgery.
→ Int Endod J.
2010 Jan;43(1):57–63.
doi:10.1111/j.1365-2591.2009.01637.x.

6.
Jang Y, Kim H, Roh BD, Kim E. Biologic
response of local hemostatic agents used
in endodontic microsurgery.
→ Restor Dent Endod.
2014 May;39(2):79–88. doi:10.5395/
rde.2014.39.2.79.
7.
Sattar MM, Patel M, Alani A. Clinical
applications of polytetrafluoroethylene
(PTFE) tape in restorative dentistry.
→ Br Dent J.
2017 Feb;222(3):151–8.
doi:10.1038/sj.bdj.2017.110.
8.
Alshehri M, Albaqiah H. Antimicrobial
efficacy of materials used for sealing
the implant abutment screw hole:
an in vitro evaluation.
→ Implant Dent.
2017 Dec;26(6):911–4. doi:10.1097/
ID.0000000000000688.
9.
Prabhakar AR, Dixit K, Raju O.
Microbiologic evaluation of cotton and
polytetrafluoroethylene (PTFE) tape
as endodontic spacer materials
in primary molars an in vivo study.
→ J Clin Pediatr Dent.
2018;42(1):21–6. doi:10.17796/10534628-42.1.4.

10.
Ghanaati S, Booms P, Orlowska A,
Kubesch A, Lorenz J, Rutkowski J,
Landes C, Sader R, Kirkpatrick C,
Choukroun J. Advanced platelet-rich
fibrin: a new concept for cell-based
tissue engineering by means of
inflammatory cells.
→ J Oral Implantol.
2014 Dec;40(6):679–89. doi:10.1563/
aaid-joi-D-14-00138.
11.
El Bagdadi K, Kubesch A, Yu X, Al-Maawi
S, Orlowska A, Dias A, Booms P, Dohle E,
Sader R, Kirkpatrick CJ, Choukroun J,
Ghanaati S. Reduction of relative
centrifugal forces increases growth
factor release within solid platelet-rich-fibrin (PRF)-based matrices:
a proof of concept of LSCC (low speed
centrifugation concept).
→ Eur J Trauma Emerg Surg.
2017 Mar 21:1–13.
doi:10.1007/s00068-017-0785-7.
[Epub ahead of print].

14.
Sauveur G, Roth F, Sobel M, Boucher Y.
The control of haemorrhage at the
operative site during periradicular
surgery.
→ Int Endod J.
1999 May;32(3):225–8.
15.
Lemon RR, Steele PJ, Jeansonne BG.
Ferric sulfate hemostasis: effect on
osseous wound healing. Left in situ for
maximum exposure.
→ J Endod.
1993 Apr;19(4):170–3.
16.
von Arx T, Jensen SS, Hänni S, Schenk
RK. Haemostatic agents used in
periradicular surgery: an experimental
study of their efficacy and tissue
reactions.
→ Int Endod J.
2006 Oct;39(10):800–8.
doi:10.1111/j.1365-2591.2006.01152.x.

12.
Dohan Ehrenfest DM, Del Corso M,
Diss A, Mouhyi J, Charrier JB.
Three-dimensional architecture and cell
composition of a Choukroun’s
platelet-rich fibrin clot and membrane.
→ J Periodontol.
2010 Apr;81(4):546–55.
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13.
Miller PD. A classification of marginal
tissue recession.
→ Int J Periodontics Restorative Dent.
1985;5(2):8–13.

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Volume 4 | Issue 4/2018 51


[52] =>
Submasseteric abscess
Submasseteric abscess

Unlikely case of submasseteric
Unlikely
case of submasseteric
abscess originating
from a maxillary
abscess
originating
from
a
maxillary
molar: The skipping lesion
molar: The skipping lesion

Abstract
OAbstract
bjective
Min Jim Lima & Alauddin Muhamad Husinb
Oral
Maxillofacial
Surgery
Department,
Hospital
Tanah
b
Kementerian
Malaysia,
Oral
Maxillofacial
Surgery
Min
Jim
Lima &Kesihatan
Alauddin
Muhamad
Husin
Merah,
Tanah
Merah,
Kelantan,
Malaysia
Department, Hospital Tanah Merah, Tanah Merah, Kelantan,
b
Maxillofacial Surgery
Surgery Department,
Department, Hospital
Hospital Tanah
Sultanah
a Oral
Malaysia
Oral
Maxillofacial
b Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia
Kementerian
Malaysia,
Oral Maxillofacial Surgery
Merah,
Tanah Kesihatan
Merah, Kelantan,
Malaysia
b
Oral
Maxillofacial
Surgery
Department,
Hospital
Sultanah
Department,
Hospital
Sultanah
Nur Zahirah,
Kuala
Terengganu,
Nur
Zahirah,
Kuala
Terengganu,
Terengganu,
Malaysia
Terengganu, Malaysia
Corresponding author:

a

Dr.
C o Min
r r eJim
s p Lim
onding author:
Oral Maxillofacial Surgery Department
Hospital Tanah Merah
Dr. Min Jim Lim
17500 Tanah Merah
Oral Maxillofacial Surgery Department
Kelantan
Hospital Tanah Merah
Malaysia
17500 Tanah Merah
Kelantan
minjimlim@hotmail.com
Malaysia
minjimlim@hotmail.com
How to cite this article:
Lim
H o MJ,
w tMuhamad
o c i t e Husin
t h i sA.aUnlikely
r t i c l ecase
: of
submasseteric abscess originating from a maxillary
molar:
skippingHusin
lesion.A. Unlikely case of
Lim MJ,The
Muhamad
Jsubmasseteric
Oral Science Rehabilitation.
2018from
Dec;4(4):52–55.
abscess originating
a maxillary
molar: The skipping lesion.
J Oral Science Rehabilitation. 2018 Dec;4(4):52–55.

O b j eabscess
c t i v e originating from a maxillary
We report a case of submasseteric
tooth, complicated by underlying diabetes mellitus and a multidrugWe
reportorganism.
a case of submasseteric abscess originating from a maxillary
resistant
tooth, complicated by underlying diabetes mellitus and a multidrugresistant organism. M a t e r i a l s a n d m e t h o d s
M a t ewith
r i a luncontrolled
s a n d m e tdiabetes
h o d s mellitus presented
A 61-year-old male patient
with swelling on the left cheek of 2 weeks in duration with rapid
A
61-year-oldto
male
patientdysphagia
with uncontrolled
diabetes
mellitus presented
progression
trismus,
and rupture
of swelling
with pus
with
swelling
on
the
left
cheek
of
2
weeks
in
duration
with
rapid
discharge. Culture and sensitivity testing revealed the presence
of
progression
to
trismus,
dysphagia
and
rupture
of
swelling
with
pus
multidrug-resistant Klebsiella pneumoniae. Based on the patient’s history
discharge.
Culture and sensitivity
testing
revealed abscess
the presence
of
and
clinical presentation,
a diagnosis of
submasseteric
originatmultidrugresistant
Klebsiella
pneumoniae.
Based onadministration,
the patient’s history
ing
from the
maxillary
molar was
made. Antibiotic
conand
clinical
presentation,
a
diagnosis
of
submasseteric
abscess
originattrol of systemic disease and wound dressing were done as treatment.
ing from the maxillary molar was made. Antibiotic administration, control of systemic disease and wound
were done as treatment.
R e sdressing
ult
R ewith
s u lscarring
t
The patient made a full recovery,
on the ruptured region.

The patient made a full recovery,
on the ruptured region.
C o n with
c l u sscarring
ion
C o ncase
c l u sof
i oinfection
n
Submasseteric abscess is a rare
that can occur in the
submasseteric space. As is commonly known, infection of the submasSubmasseteric
abscess from
is a rare
case of infection
that hence,
can occur
in the
seteric space originates
mandibular
third molars;
maxillary
submasseteric
As is commonly
infection
of the
molars seem tospace.
be an unlikely
source ofknown,
infection.
Diagnosis
of submassubmasseteric
space
originates
from
mandibular
third
molars;
hence,
maxillary
seteric abscess that originates from maxillary molars can be difficult
molars
seem
to be and
an unlikely
source
of infection.
Diagnosis
ofdiagnosis
submasowing to
its rarity
thus the
unlikeliness
of being
the first
seteric
abscess
that originates from maxillary molars can be difficult
that comes
to mind.
owing to its rarity and thus the unlikeliness of being the first diagnosis
that comes to mind.
Keywords
Keyw
o r d sskipping lesion.
Submasseteric abscess; maxillary
molar;

52 Volume 4 | Issue 4/2018
52 Volume 4 | Issue 4/2018

Submasseteric abscess; maxillary molar; skipping lesion.
Journal of
Oral Science & Rehabilitation
Journal of
Oral Science & Rehabilitation


[53] =>
Submasseteric abscess

Introduction
Submasseteric abscess is a rare complication
that commonly has dental origins, particularly
the mandibular third molars.1 However, the
development of a submasseteric abscess from
maxillary molars is scarcer. We could find only
1 case report in our literature search.2 Owing to
the rarity and late symptomatic manifestation
of such cases, diagnosis may not be easy for the
general practitioner. Management of submasseteric abscess can be further complicated in
patients with impaired immune systems or
infected with multidrug-resistant organisms. In
this article, we would like to highlight the case
of a patient who presented with a rare submasseteric abscess from an unlikely origin, complicated by uncontrolled diabetes and a multidrug-resistant organism.

Case report
A 61 -year-old male patient with underlying
diabe tes mellitus presented to the Dental
Department with the chief complaint of swelling on the left cheek with a duration of 2 weeks.
The patient claimed that the swelling had begun
at the left angle of the jaw and had been increasing in size. The swelling was accompanied by
severe throbbing pain and difficulty in swallowing. Upon further probing, the patient said that
he had undergone a difficult and unsuccessful
extraction of the maxillary left second molar
2 weeks prior.
Upon physical examination, there was a
large, diffuse swelling on the left face involving
the left masseter region and extending to the
left submandibular region with the loss of palpable mandibular angle (Fig. 1). The swelling
was firm, tender, warm and erythematous. The
patient was also experiencing trismus, with
mouth opening of 20 mm interincisally. Intraoral
examination revealed poor oral hygiene and a
retained root of the maxillary left second molar,
which was tender to percussion. The gingiva
surrounding the retained root of the maxillary
left second molar was assessed to be sufficiently healed, without any signs of infection.
The teeth and the gingiva on the opposing arch
were healthy. An immediate diagnosis of submasseteric cellulitis with possible involvement
of the lateral pharyngeal space was made. The
patient was immediately warded and given
intravenous crystalline penicillin 4 mega units

statim, followed by 2 mega units every 6 h. The
patient was also referred to the medical department for management of underlying diabetes
mellitus. The patient was prescribed a 500 mg
metformin oral tablet once daily. Aspiration was
done with a size 16 syringe needle, but yielded
no product. It was regrettable that a CT scan
was not available at that time.
On day 5 after admission, there was a breakdown of the overlying skin with pus discharge
at the left posterior submandibular region,
extending to the submasseteric region. The
margin of the wound was friable and necrotic.
However, the patient claimed that the pain had
subsided with the absence of dysphagia. Wound
debridement was done, and it was irrigated with
chlorhexidine and normal saline. A rubber tube
was placed to allow further drainage (Fig. 2).
Topical metronidazole was placed on the wound
and covered with gauze. A swab was taken and
sent for culture and sensitivity testing. The result
was penicillin-resistant Klebsiella pneumoniae
with sensitivity to cefuroxime. Hence, cefuroxime
was chosen as a replacement for penicillin. Daily
wound dressing was done, together with the
placement of topical metronidazole.
On day 13, the swelling over the left submandibular and submasseteric region had subsided.
The patient did not have any dysphagia or trismus. There was no more pus discharge from the
wound or from the rubber drain, and only a raw
wound was exposed (Fig. 3). After the rubber
drain had been removed, a wound dressing was
done and the wound was left to heal by secondary intention. A full-mouth scaling and removal
of the retained root of the maxillary left second
molar were done. The patient was then discharged with a weekly appointment for review
and wound dressing.
The patient was followed over a 2-month
period. At the last follow-up, the patient
presented with scarring of the area posterior to
the left angle of the mandible that was slightly
darker than the surrounding skin, but with
minimal contracture (Fig. 4).

Discussion
In 1948, Bransby-Zachary described a potential
space that constitutes a masticator space known
as the submasseteric space.3 He mentioned that
the common cause of submasseteric space
infection was pericoronitis of the third molar.3
The submasseteric space is a potential space

Journal of
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Volume 4 | Issue 4/2018 53


[54] =>
Submasseteric abscess

Fig. 1

Fig. 1
Swelling of the left of the
face involving the
left masseter region.
Fig. 2
A rubber drain was placed
for pus drainage.

formed between the lateral wall of the mandible
and the medial aspect of the masseter muscle
and its investing fascia. Submasseteric abscess
is often not the foremost diagnosis when a
patient complains of swelling of the jaw owing
to its rarity.1 A study has shown that the most
commonly involved orofacial space is the submandibular space, followed by the buccal space
and lastly the submasseteric space.4 It is often
thought to be trismus, as its first sign is spasm
of the masseteric muscle, resulting from the
irritation of the muscle fiber by the infection.
Extraoral examination cannot determine its
severity, as the swelling is often firm and mild
in the early stages, owing to its being confined
by the masseteric muscle. The swelling is isolated, involving the angle of the mandible, and
tender and diffuse in nature. Once the infection
penetrates the muscle fibers, the swelling
becomes fluctuant and erythematous. 5
The submasseteric space is connected to
other spaces, including the buccal space, submandibular space, pterygomandibular space and
infratemporal space. However, the submasseteric space is by no means directly connected to
any maxillary teeth. It would seem rather impossible for the maxillary molar to be the origin of
the submasseteric abscess. We postulated that,
according to the patient’s history, an infected
hematoma may have formed in the buccal space
or infratemporal space, owing to the traumatic
and unsuccessful extraction. However, the healing of the gingiva at the extraction site proceeded normally, without any signs of infection.
This meant that there was a formation of an
isolated and infected hematoma. The infected
54 Volume 4 | Issue 4/2018

Fig. 2

hematoma was presumed to have extended into
the submasseteric space, without having
infected the buccal space or the infratemporal
space tissue. This gave an impression of the
infection skipping through the aforementioned
space to the submasseteric space.
We were only able to find 1 other similar
case, which was reported by Gallagher and
Marley, for which they hypothesized that an
infected hematoma was formed at the infratemporal region before extending into the submasseteric space.2
K. pneumoniae is frequently isolated as a
major infective organism in diabetic patients.
Empirical antibiotic therapy of amoxicillin with
clavulanic acid together with metronidazole,
coupled with surgical drainage, should provide
a satisfactory outcome.4 However, in this patient,
owing to the presence of penicillin-resistant
K. pneumoniae, the patient’s condition did not
respond to the administration of penicillin and
rapidly deteriorated. By the time we had obtained
the microbiology results, the abscess had ruptured through the overlying skin. After changes
were made in the antibiotic administration, there
was a significant improvement of the wound. We
noticed a significant reduction in pus discharge
from the wound and an increase in healthy granulation tissue formation. It is regrettable that,
owing to the rapid progression of the infection,
we could not prevent the breaking down of
superficial tissue, leading to permanent scarring.
The control of the patient’s diabetic condition was a major concern in our management.
Diabetes has been considered a factor reducing
host response, as it may lead to hyperglycemia,

Journal of
Oral Science & Rehabilitation


[55] =>
Submasseteric abscess

Fig. 3

Fig. 3

disrupt cellular immunity and complement
activation. Complication of deep neck infection
is also frequently reported in patients with
diabetes. 4
The management
of this patient
would have
disrupt
cellular immunity
and complement
been greatly
improved ifofadeep
CT scan
been
activation.
Complication
neckhad
infection
available.
The diagnosis
is
also frequently
reportedofinsubmasseteric
patients with
4
abscess would have been made much earlier.
diabetes.
With
CTmanagement
imaging as aofguide,
a proper
incision
The
this patient
would
have
and drainage
haveif been
provide
been
greatly would
improved
a CT done
scan to
had
been
an outlet for
thediagnosis
abscess, preventing
a breakavailable.
The
of submasseteric
down
of the
overlying
tissue.
abscess
would
have been
made much earlier.
With CT imaging as a guide, a proper incision
and drainage would have been done to provide
an outlet for theConclusion
abscess, preventing a breakdown of the overlying tissue.
This case highlights what seems to be an impossible diagnosis. While the submasseteric space
is not a neighboring
space of maxillary teeth, the
Conclusion
possibility of the spread of infection exists. At
present,
paper addresses
the risk
level
such
This
caseno
highlights
what seems
to be
an of
imposa complication
of thethe
extraction
of maxillary
sible
diagnosis. While
submasseteric
space
teeth.
Severe systemic
disease
or teeth,
a multiis
not a neighboring
space of
maxillary
the
drug-resistant
organism
be the exists.
culprit At
of
possibility
of the
spread could
of infection
such a seemingly
impossible
diagnosis.
It is
present,
no paper addresses
the risk
level of such
that, from
practitioners
will
ahoped
complication
ofthis
the paper,
extraction
of maxillary
be made
aware
of suchdisease
complications
and
teeth.
Severe
systemic
or a multiprompted to investigate
to manage
such
drug-resistant
organismfurther
could be
the culprit
of
a caseainseemingly
a timely manner.
such
impossible diagnosis. It is
hoped that, from this paper, practitioners will
be made aware of such complications and
Acknowledgment
prompted to investigate
further to manage such
a case in a timely manner.
This case report was supported by the Oral
Maxillofacial Surgery Department (Unit Bedah
Mulut), Hospital
Tanah Merah, Malaysia.
Acknowledgment

S u bFig.
m4a s s e t e r i c a b s c e s s

Fig. 4

Competing
interests
We would like
to thank the
Director General of
Health Malaysia for his permission to publish
The
this authors
article. declare that they have no competing interests.
Competing interests
The authors declare that they have no competing interests.

References
1.
Jones KC, Silver J, Millar WS, Mandel L.
Chronic submasseteric abscess:
References
anatomic, radiologic,
and pathologic
features.
→ AJNR Am J Neuroradiol.
2003 Jun–Jul;24(6):1159–63.
1.
Jones KC, Silver J, Millar WS, Mandel L.
2.
Chronic submasseteric abscess:
Gallagher J, Marley J. Infratemporal and
anatomic, radiologic, and pathologic
submasseteric infection following
features.
extraction of a non-infected maxillary
→ AJNR Am J Neuroradiol.
third molar.
2003 Jun–Jul;24(6):1159–63.
→ Br Dent J.
2003 Mar;194(6):307–9.
2.
Gallagher J, Marley J. Infratemporal and
3.
submasseteric infection following
Bransby-Zachary GM. The submasseteric
extraction of a non-infected maxillary
space.
third molar.
→ Br Dent J.
→ Br Dent J.
1948;84:10–3.
2003 Mar;194(6):307–9.
4.
3.
Rao DD, Desai A, Kulkarni RD,
Bransby-Zachary GM. The submasseteric
Gopalkrishnan K, Rao CB. Comparison of
space.
maxillofacial space infection in diabetic
→ Br Dent J.
and nondiabetic patients.
1948;84:10–3.
→ Oral Surg Oral Med Oral Pathol Oral
Radiol Endod.
4.
2010 Oct;110(4):e7–12.
Rao DD, Desai A, Kulkarni RD,
Gopalkrishnan K, Rao CB. Comparison of
5.
maxillofacial space infection in diabetic
Hupp JR, Ellis E, Tucker MR. Contempoand nondiabetic patients.
rary oral and maxillofacial surgery. 5th ed.
→ Oral Surg Oral Med Oral Pathol Oral
→ St. Louis, MO: Mosby; 2008. 728 p.
Radiol Endod.
2010 Oct;110(4):e7–12.

This case report was supported by the Oral
5.
Journal
of JR, Ellis E, Tucker
Volume 4 | Issue 4/2018 55
Hupp
MR. ContempoMaxillofacial Surgery Department (Unit Bedah
Oral Science & Rehabilitation
rary oral and maxillofacial surgery. 5th ed.
Mulut), Hospital Tanah Merah, Malaysia.
→ St. Louis, MO: Mosby; 2008. 728 p.

Fig. 3
Healing of the perforated
wound.
Fig. 4
Fig. 3
Scarring at the area posterior
Healing
of angle
the perforated
to the left
of the
wound.
mandible.
Fig. 4
Scarring at the area posterior
to the left angle of the
mandible.


[56] =>
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Journal of
Oral Science & Rehabilitation

Dental Tribune International Publishing Group
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Volume 4 | Issue 4/2018

57


[58] =>
Imprint: About the publisher

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58 Volume 4 | Issue 4/2018

Journal of
Oral Science & Rehabilitation


[59] =>
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