Tissue Augmentation 2012

494 Posters Tissue Augmentation and
Engineering
The use of Platelets rich fibrin (PRF) in

reconstructive dental implant treatment
Ahmed Ayoub
Egyptian Society of Oral Implantology, Alexandria, Egypt
Background: When minimal bone width is present, implant
placement becomes a challenge and often resulting in recession and dehiscence around the implant that leads to subsequent gingival recession. To correct such defect, soft tissue
autografting and allografting to correct a buccal dehiscence
around a malpositioned implant placed by a different surgeon
is used. Platelet-rich fibrin (PRF) belongs to a new generation
of platelet concentrates, with simplified processing and without biochemical blood handling, it is a strictly autologous
fibrin matrix containing a large quantity of platelet and leukocyte cytokines. The use of platelet gel to improve soft and
hard tissue regeneration is a recent technique in implantology.
So in this case the PRF is used to the dehiscence.
Aim: The aim is to cover the exposed implant threads using
PRF instead of using bone grafts and connective tissue grafts.
Methods: A healthy 24-year-old woman presented with chief
complaint of my implant is showing through my gingival tissue. Patient was wondering if there is any periodontal treatment available to mask the showing of implant threads
through the gingival tissue and prevent further recession.
With excellent oral hygiene, upon clinical examination, there
was minimal buccal gingival thickness around the implant in
upper central incisor. Her recent dental history included
extraction of permanent tooth #24, and an immediate implant
was placed in site #24. Her previous dental treatment was rendered by a different surgeon. The patient presented to Dental
smile center 4 months after implant placement. The implant
appeared to be osseointegrated with a buccal dehiscence and
1020% of facial implant showing through gingival tissue due
to minimal bone width. Since the implant was osseointegrated, removal of implant was not considered fearing damage
to adjacent teeth when trephining the implant. Also, due to
loss of buccal bone cortex, The positioning of implant outside
the bony envelope and possible sloughing of fragile buccal
Gingival tissue-guided bone regeneration were not recommended. Faced with the esthetic concerns and possible future
recession around that implant, soft tissue gingival grafting
was recommended to augment the keratinized gingiva and
improve esthetics.
Results: From a radiologic and histologic point of view at
4 months after surgery, the use of PRF as the sole filling or
covering material stabilized a high volume of natural regenerated bone and soft tissue over the exposed implant threads.
Choukrouns PRF is a simple and inexpensive biomaterial,
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and its systematic use during covering bony defect above

implant seems a relevant option.
Conclusions and clinical implications: The use of PRF membrane could cover the exposed implant threads instead of
using traditional bone grafts and connective tissue grafts.

Engineering
Implants in a patient with bilateral cleft lip and

palate
Davor Brajdic, Darko Macan, Domagoj Zabarovic,
Josip Biocic
School of Dental Medicine, Universitiy Hospital Dubrava,
Zagreb, Croatia
Background: Dentoalveolar rehabilitation in patients with cleft
lip and palate represents a clinical challange. Conventional

treatment options including fixed prosthesis and/or assistant
orthodontic treatment are nowadays increasingly replaced by
endosseous implants. Besides the most frequently lacking
or malformed lateral incisors there is often not enough bone
volume after primary bone grafting.
Aim: Secondary bone grafting prior to dental implant placement in a patient with a bilateral cleft lip and palate.
Methods: We present a case of a 28-year-old male patient with
a bilateral cleft lip and palate who rejected the conventional
rehabilitation with fixed partial prosthesis and insisted on
placement of two dental implants. The treatment was preceeded by augmentation of alveolar bone. Prior to treatment CBCT
was performed and showed only narrow alveolar bone bridges
at the cleft positions. At the upper right lateral incisor position bone bridge was more palatal, at the left position more
vestibular. Only one mandibular ramus block was harvested,
splitted and mixed with particulate xenograft (Bio-Oss,
Geistlich, Germany) as an onlay vestibular graft at the right
position and as onlay palatal graft at the left. Resorbable membrane (Bio-Gide , Geristlich, Germany) was used. Six months
later two dental implants (Ankylos , Dentsply Friadent,
Germany) were placed at augmented places that after three
more months were loaded with metal cheramic crowns. Bone
and soft tissue volume were satisfactory.
Results: After a 2-year follow-up a satisfactory esthetic and
functional result could be observed.
Conclusions and clinical implications: These patients require
secondary bone grafting not only to achieve sufficient osseous
support for functionally loaded implants, but also to achieve
an appropriate alveolar bone volume for a satisfactory esthetic
result. Moreover, functional stimulation of the implant limits
resorption of the grafted bone.

Engineering

Engineering
Mineralized human allograft for the preservation

of post-extraction socket
Titanium micromesh
Marco Clementini,1 Gianluca Furlani,1 Giulia

Dobrenji,1 Corrado Agrestini,1 Davide Zaffe,2
Alberto Barlattani1
Fondazione IRCCS Ca` Granda Fondazione policlinico, Milano,
University Tor Vergata, Rome, Italy, 2University of Modena and

Reggio Emilia, Modena, Italy
Background: Reduction of alveolar height and width after
tooth extraction could be unfavourable for future implant

placement, especially in the anterior maxilla where bone volume is significant for biologic and esthetic reasons. During
the last years various biomaterials and surgical techniques
have been described to maintain dimensions of the residual
alveolar ridge, thus allowing a tridimensional correct implant
placement for a final esthetic implant supported restoration.
Aim: The objective of the present investigation was to evaluate the efficacy of a surgical technique using mineralized
human allograft on counteracting dimensional changes of the
alveolar socket after tooth extraction.
Methods: In 10 patients, 10 single extraction sites in the anterior area were grafted by means of mineralized human allograft and was covered by a collagen membrane in all cases.
Intraoral radiographs and clinical measurement were taken at
baseline and after 4 months. At that time a reentry surgery
was performed and prior to implant placement a biopsy core
was obtained and preserved in formalin to calculate fractions
of bone mineral, connective tissue and residual graft material.
Results: After 4 months of healing the intraoral radiographs
showed a mean differcence of bone level heigth of 0.78
(SD 0.79) mm., while clinical measurements showed a mean
reduction of 1.2 (SD 0.9) mm. in width, allowing to accept
normal diameter implants. The specimens harvested showed a
mean of 31.9% of mineralized bone, 54.2% of connective tissue, and 13.93% of residual graft.
Conclusions and clinical implications: The results of this study
show that although some degree of bone modelling and
remodelling will occur after tooth extraction, a surgical technique using mineralized human allograft resulted in significantly less vertical and horizontal contraction of the alveolar
bone crest, suggesting that it may be useful for alveolar ridge
preservation prior to dental implant placement, especially in
the esthetic region.
Giulio Conti
Italy
Background: Different techniques for atrophic alveolar bone
ridges reconstruction are described in literature, such as

resorbable and non-resorbable membranes and titanium
micromeshes. During the last years titanium meshes, in
association with autologous and heterologous bone, have been
used and tested in oral surgery for partial or total alveolar
ridges augmentation.
Aim: Aim of this work was to present cases describing the
use of titanium micromesh combined with autologous and
heterologous bone grafts in patients affected by alveolar bone
resorption.
Methods: Before surgery, a radiologic investigation based on
panoramic radiography and computed tomography (CT DENTALSCAN) was performed. During surgery, after opening a
full thickness flap, a titanium mesh was prepared according to
the effective size of the bone defect (misured with a periodontal probe). The mesh was fixed to the bone using titanium
mini-screws and/or pins. Before mesh positioning, heterologous (Geistlich Bio-Oss) and autologous bone chips were
applied under the grid to fill the bone defect. Before closing
the flap and suturing, a resorbable membrane (Geistlich BioGide) was used to cover the mesh. Approximately 5 months
after first surgery, the mesh was removed, and at the same
time dental implants (GLOBAL, Sweden and Martina, Italy)
were postioned in order to reduce postoperative discomfort
and avoid a third surgery.
Results: In all the cases, a good increase of the alveolar bone
ridge to insert implant fixtures with good primary stability
and without necessity for further regeneration was obtained.
In one of the cases, an early exposure of the mesh was
observed after 2 weeks. However, this event didnt compromised the outcome of the procedure.
Conclusions and clinical implications: Titanium mesh is a reliable containment system used for reconstruction of the maxilla and the mandible. This material tolerates exposure very
well and gives predictable results.
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Engineering
A novel cellulose hydroxyapatite scaffold for

bone tissue regeneration
Povilas Daugela,1 Gintaras Juodzbalys,1
Jolanta Liesiene,2 Odeta Petrauskaite,2 Pedro Gomes,3
Elisabete Costa4
1
Lithuanian University of Health Sciences, Kaunas, Lithuania,

Kaunas University of Technology, Kaunas, Lithuania,
2
3
University of Porto, Porto, Portugal, 4CICECO, University of
Aveiro, Aveiro, Portugal

Background: Nowadays much attention is focused on polymer-
ceramic three-dimensional scaffolds for bone tissue regeneration in defect site. For a successful performance the ideal
scaffold should be a 3D interconnected porous structure able to
promote cell adhesion, proliferation and vascularisation, while
enabling a controlled supply of bioactive substances that might
influence the behaviour of incorporated or ingrown cells.
Aim: To investigate a novel cellulose-based porous composites with hydroxyapatite for the bone scaffold.
Methods: The composites were fabricated by saponification of
diacetylcellulose adding hydroxyapatite. After the reaction the
obtained gel of regenerated cellulose was homogeneously
immobilized with hydroxyapatite. In order to create suitable
matrix the composites were freeze-dried.
Results: It was found out that the conditions of lyophilisation
highly influenced the morphology of the matrix. The porosity
of the scaffolds was up to 75% with pores of different sizes up
to 770 lm. The results of bioactivity test in vitro showed that
bone-like apatite appeared onto the surface after 7 days of
immersion in simulated body fluid. Furthermore, the behaviour of MG-63 human osteoblastic-cells on investigated cellulose matrix was examined. It was found that the scaffolds are
not cytotoxic and induce the growth of the cells.
Conclusions and clinical implications: From the obtained results
it could be concluded that prepared scaffolds have a great
potential for bone tissue ingrowth in vivo. Attained results
substantiate the suitable application of cellulose/hydroxyapatite scaffolds in bone tissue engineering applications.

Engineering
Homogenous bone block for the reconstruction

of severely resorbed maxilla
Bruno Fusaro1,2
1
Professor Coordinator of the Postgraduate Program in Implant
DentEstacio de Sa University, Juiz De Fora, Brazil, 2Masters
degree in Implantology by University of Sagrado Coracao, Bauru,

Brazil
Background: Pre-implant augmentative surgery is a prerequisite in many cases in the severly resorbed maxilla to achieve a
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stable, long-term esthetic final result. Homogenous grafts are

among of the most used techniques for bone reconstruction.
Aim: The aim of the present study was evaluate by CT scans
the bone improvement after grafting with freeze block bone
homogenous in severely resorbed maxilla, including horizontal
gain in the region of canine fossa and vertical gain in maxillary sinus.
Methods: Six patients (3 male, 3 female) aged between 38 and
65 years-old underwent 18 bone homogenous blocks in 12
sinus elevation and 12 canine fossa regions augmentation. The
elevation of the maxillary sinus floor was made by particulate
block. After 8 months CT mensurements were taken at the
canine fossa region, based on the distal surface of the nasal
cavity and on sinus region. Two examiners used specific software on the images obtained by CT to measure the bone
improvement. Implants were placed 8 months after the first
surgery.
Results: Minor complications such as wound dehiscence and
bone blocks superficial necrosis were observed however the
results showed an average gain of 5.9 mm on fossa canine
regions and 8.4 mm on the maxillary sinus region.
Conclusions and clinical implications: It was concluded that
there was a considerable bone gain and good implant primary
stability so homogenous bone block appear to hold promise
for grafting the atrophic maxilla.

Engineering
Adsorbed Periostin protein on titanium surfaces

affects osteoblastic cell behavior
Carlo Galli, Simone Lumetti, Marilina Piemontese,
Giovanni Passeri, Guido Macaluso
University of Parma, Parma, Italy
Background: In tissue engineering, stimulating the cells to dif-
ferentiate into the right phenotype to regenerate the tissue

lost requires an environment providing the same factors that
govern cellular processes in vivo. A biomimetic approach to
tissue engineering requires to direct the assembly of normal
tissues using biologically mimicking the signals present in the
extracellular matrix (ECM). Periostin is a matricellular protein
highly expressed in periodontal ligament and periostium and
it is up-regulated during tissue remodeling and wound repair.
Periostin has been shown to be required for the stability,
maintenance and mechanotransduction in bone. We have
therefore hypothesized that Periostin can be used to coat
implant surfaces, to promote osteoblast differentiation and
therefore surface integration in the tissue.
Aim: The goal of the present study was to investigate whether
Periostin coating could improve the response of osteoblastic
cells to implant surfaces with different topography.
Methods: Polished or sand-blasted/acid-etched (SLA) commercially pure titanium surfaces were incubated with a 20 mg/ml
solution of recombinant Periostin and the murine osteoblastic
cell line MC3T3 was cultured on coated or uncoated discs in
complete DMEM with 10% Fetal Bovine Serum. Cell adhesion

was measured with a ATP-based bioluminescent assay (CellTiter Glo; Promega) and the expression of osteoblastic function-related genes was quantified by Real Time PCR.
Results: Periostin increased cell adhesion on Polished surfaces
at 4 h and increased the expression of Alkaline Phosphatase,
Osteoprotegerin and Connective Tissue Growth Factor on
smooth surfaces, although it did not affect them on SLA samples. Levels of mRNA for Collagen1a1, the main structural
component of extracellular matrix, and Osteocalcin, a late
marker of osteoblastic phenotype, were higher in cells growing
on coated Polished surfaces, but were respectively lower or
unchanged on SLA.
Conclusions and clinical implications: Taken together these
results show that adsorbed Periostin can improve cell
responses to titanium surfaces. However surface topography
can affect the cellular effects of this protein, most likely by
impairing its adsorption. Alternative methods for surface functionalization must be therefore researched, to ameliorate
Periostin effects on rough titanium.

Engineering
Initial density affects the resorption of bone

block allografts
Simone Lumetti,1 Claudio Marchetti,2 Ugo Consolo,3
Luigi Piersanti,2 Alessandra Multinu,3 Giulia
Ghiacci,1 Carlo Galli,1 Guido Maria Macaluso1
1
University of Parma, Parma, Italy, University of Bologna,
(998 232 HU). The mean density variation was 9% in the

control group and 8% in the test group. No significant differences were observed in density changes between the groups
(P = 0.57). The Pearson test revealed that no correlation
between inital density and degree of resorption existed for
autologous bone grafts, while such a correlation was significant for fresh-frozen bone grafts. Less dense grafts tended to
lose more volume than denser grafts: average volume resorption for <800 HU fresh-frozen bone was 57%, whereas it was
15% when initial density was >800 HU (P = 0.001).
Conclusions and clinical implications: Fresh-frozen bone grafts
used in this study had a wide density range, depending on the
portion of tibia they come from: this fact made possible to
highlight a correlation between initial density and volume
change. On the other hand, autologous bone grafts had a limited density range and this may have hindered the possibility
to show such a correlation, which has been reported in previous studies. Basing on these data, we may conclude that bone
grafts with a density >800 HU are preferable to less dense
grafts, due to their lower degree of resorption. Further studies
which analyze the behavior of autologous bone grafts with a
wider density range are recommended.

Engineering
Platelet rich fibrin (PRF) as a matrix for human

osteoblast cell cultivation
Volker Gassling,1 Nicolai Purcz,1 Jurgen Hedderich,2
Timothy Douglas,3 Yahya Acil,1 Jorg Wiltfang1
Bologna, Italy, 3University of Modena and Reggio Emilia, Modena
and Reggio Emilia, Italy
Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany,
Department of Oral and Maxillofacial Surgery, University
Institute of Medical Informatics and Statistics, University
Background: Bone graft composition and microarchitecture
Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany,
strongly affect their biological behavior. Density represents a

quantifiable parameter which may be related to the resorption
pattern, as denser cortical grafts may perform differently from
less dense trabecular grafts.
Aim: The aim of this study was to retrospectively evaluate
the correlation between initial density and 6 months resorption of autologous and fresh-frozen bone grafts used for horizontal ridge augmentation.
Methods: Thirty-eight grafts were performed, 17 of autologous
bone and 21 of fresh-frozen bone. Autologous bone blocks
were harvested from intraoral sites, while homologous blocks
from tibial hemiplateau were provided by Banca del tessuto
muscolo-scheletrico (IOR, Bologna, Italy). Patients received
CT scans respectively 1 week and 6 months after surgery,
which were used for density and volume analysis. Students
t test was applied to evaluate differences in density change.
Linear regression analysis and Pearson correlation test were
used to investigate the correlation between parameters. The
level of significativity was set at P < 0.05.
Results: The mean initial density of homologous bone grafts
was (708 335 HU) and it resulted to be significantly lower
(P = 0.0099) than the density of autologous bone grafts
Department of Organic Chemistry, University of Ghent, Ghent,
Belgium, Gent, Belgium

Background: An essential precondition for new bone formation
is an extracellular matrix in which osteoblastic cells can

migrate, differentiate and proliferate. Platelet rich fibrin (PRF),
a biopolymer has been shown to support the bone regeneration
in clinical applications.
Aim: The aim of this in-vitro study was to assess whether
membranes or clots of PRF promote the proliferation and differentiation of osteoblast cells.
Methods: Human osteoblasts were cultivated on PRF clots,
PRF membranes or collagen membranes (n = 10 per group).
The alkaline phosphatase activity (ALPA), a marker of osteoblast differentiation, was measured in the supernatant over a
period of 36 days. Osteoblast cultures with eluates of PRF
membranes (n = 7) and collagen membranes (n = 8) were used
to analyse cytotoxicity and proliferation promoting effects
with the lactate dehydrogenase (LDH) test and BrdU (5-bromo2-deoxyuridine) test, respectively. Proliferation of human
osteoblasts cultured on platelet rich fibrin membranes or
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collagen membranes was analysed by the water soluble tetrazolium (WST-1) test.
Results: The increase of ALPA as an indicator of osteoblastic
differentiation was higher in cultures on PRF clots and membranes compared to collagen membranes. The BrdU test
showed a higher proliferation of human osteoblasts cultured
with eluates from PRF membranes than with eluates from collagen membranes, respectively. This is in accordance with the
findings of the WST-1-proliferation test that showed higher
cell proliferation for the human osteoblasts cultured on PRF
membranes than on collagen membranes.
Conclusions and clinical implications: PRF clots and membranes has been shown to be suitable as scaffold for human
osteoblast cell cultivation.

Engineering
Keratinized tissue augmentation by means of a

new matrix
Carlo Maiorana, Alessandra Gatto, Luca Pivetti,
Mario Beretta
Department of Dental Implants, Fondazione IRCCS Ca` Granda,
University of Milan, Ospedale Maggiore Policlinico, Milan, Italy
6 months showed less than 20% contracture (considered as

excellent), while the other 12 were found inferior to 50%
(good). Clinically it has been observed a level of regenerated
keratinized tissue as the adjacent areas. The regenerated tissue
looks smooth, without any dyschromia, and a nice vascular
network can be appreciated. All subjects reported low discomfort, identified as a level 1 of Mankosky pain scale.
Conclusions and clinical implications: Matrix resorption is slow
enough to lead re epithelization and guarantee a deeper vestibule, therefore to reach healthy and aesthetical success. This
last aspect in particular is enhanced by a perfect tissue integration. In addiction, post-surgical morbidity is very little
compared to autogenous soft tissue grafting techniques

Engineering
Effect of low level laser irradiation on bone

marrow mesenchymal stromal cells for bone
tissue regeneration
Marco Giannelli,1 Alessandro Pini,2 Chiara Sassoli,3
Flaminia Chellini,3 Roberta Squecco,4 Benedetta
Mazzanti,5 Daniele Bani,3 Lucia Formigli3
1
Odontostomatologic Laser Therapy Center, Florence, Italy,
Background: A good level of keratinazed tissue is not proven
to effect implant success rate, but is important for oral

hygiene procedures. Nowadays there are three different kind
of graft that can be used to achieve gingival augmentation:
autogenous, allogenic and xenogenic grafts. The last group is
generally of bovine or porcine origins. This kind of grafts are
deprived from cellular components, but preserve extracellular
matrix, collagen and elastic fibres, therefore presenting the
same regenerative capabilities.
Aim: The purpose of this investigation was to study the clinical results utilizing a collagen matrix as a substitute for soft
tissue autografts in patients restored by conventional prosthesis or implant-based prosthesis, where a vertical and horizontal increase of keratinized soft tissue is necessary.
Methods: The surgery starts with a split thickness longitudinal incision, followed by two lateral incisions. The coronal
edge of the mucosal flap is fixed to the periosteum in the
depth of the vestibule. The exposed area is covered with the
collagen matrix (Mucograft, Geistilich Pharma AG, Wolhusen, Switzerland), which is stitched with nylon sutures. Half
of the stitches will remain for 4/6 weeks to determine the outline of the incision, this is important to evaluate the re epithelization. An acrylic splint is placed upon the surgical site and
remains on site for 10 days in order to avoid muscular insertion migration in a coronal direction. Patients are controlled
at 3, 10 days, 2, 3, 4, 8 weeks and then at 6 months after the
surgery. During every visit the amount of keratinized tissue
gain as well as re epithelization and contracture of the graft
are measured and photographed.
Results: In the 10 patients treated re epithelialization was
complete at 4 weeks. The 20 measures collected after
232
Preclinical and Clinical Pharmacology,, Florence, Italy,

Anatomy, Histology and Forensic Medicine, Florence, Italy,
3
4
Physiological Sciences, Florence, Italy, 5Haematology, Placental
Blood Bank, Careggi Hospital, Florence, Italy

Background: Reconstruction and rehabilitation of acquired
defects or loss of teeth of the oral cavity is an important

dental service. Severe deformities of the bone due to trauma,
atrophy or periodontitis injuries may cause alveolar bone and
soft tissue reduction and interfere with implant-prosthetic
rehabilitations. Mesenchymal stromal cells (MSCs) have been
shown to be a promising source of adult stem cells for cell
transplantation and bone repair/regeneration. The use of these
cells in cell therapy requires their expansion in vitro in order
to obtain an adequate amount of cells to be implanted in the
injured tissue. Therefore, improvements of their proliferative
potentials during in vitro culture can significantly shorten cell
preparation time and avoid contamination, thus contributing
to the further development of cell-based tissue regeneration.
Low-level laser irradiation (LLLI) may represent a promising
approach to stimulate cell proliferation.
Aim: In the present study we investigated the effects of
635 nm diode laser on mouse MSC proliferation and the
underlying cellular and molecular mechanisms.
Methods: Mouse bone marrow mesenchymal stromal cells
(MSCs) were isolated from femura and tibiae of male C2F1
mice. MSCs in growth medium were stimulated with a diode
laser 635 nm in continuous irradiation mode (power 89 mW;
energy density dose of 0.26 J/cm2; laser output was coupled to a
0.6-nm-diameter optical fiber) and assayed for cell viability and
proliferation by MTS assay, Time lapse videomicroscopy and
EdU incorporation. Expression of Notch-1 and its target gene
Hes-1 were evaluated in MSCs cultured in the absence or

presence of 0.5 mM Ba2+, to inhibit KCa1.1 chennels, using RTPCR, Western Blot and confocal immunofluorescence Ionic currents were recorded with the whole-cell patch clamp technique.
Results: It was found that MSC proliferation was significantly
enhanced after laser irradiation and this phenomenon was
associated with the up-regulation and activation of Notch-1
pathway, and with increased membrane conductance through
voltage-gated K+, BK and Kir, channels and T-and L-type Ca2+
channels. We also showed that MSC proliferation was maily
dependent on Kir channel activity, on the basis that the cell
growth and Notch-1 up-regulation were severely decreased by
the pre-treatment with the channel inhibitor Ba2+ (0.5 mM).
Interestingly, the channel inhibition was also able to attenuate the stimulatory effects of diode laser on MSCs, thus providing novel evidence to advance our knowledge on the
mechanisms of biostimulation after LLLI.
Conclusions and clinical implications: In conclusions, our findings suggest that diode laser (630 nm) may be a valid and safe
approach for the preconditioning of MSCs in vitro prior cell
transplantation for bone repair and regeneration.
placed in the alveolar mucosa facial or lingual to the tightened

implant already. These pouch-like preparations were performed
where lack of keratinized gingiva or localized deficiency of bone
and soft tissue was found. At the start of flapless implant placement a punched gingival tissue taken with trephine (4 mm in
diameter) was deepithelized and preserved in saline. Finally,
this connective graft was placed into the pouch in order to gain
the apico-coronal augmentation of soft tissue profiles.
Results: 636 months after mucogingival therapy, <9> =
16.0 11.8 months, seven cases demonstrated increase in the
width of KGT in apico-coronal direction reaching <9> =
2.8 0.4 mm where previously the thickness was inadequate.
The probing pocked depths of controlled sites were
<9> = 2.4 0.9 mm. The last patient showed marked gain
and improvement of earlier deficient soft tissue profile
6 months after treatment.
Conclusions and clinical implications: Our preliminary data suggest that preserved punched deepithelized gingival tissue grafts
integrate well and gingiva reaches adequate thickness and KGT
width few months after surgery. This contributes to improved
maintenance of stable peri-implant soft tissue environment.

Engineering

Engineering
Thickening of peri-implant mucosa using

punched gingival graft
Clinical and tomographic analysis of the increase

in height and implant success after sinus lift: a
2-year follow-up
Dusan Groselj,1 Astrid Razem,2 Mateja

Zvokelj-iglicar,3 Helena Groselj1
1
MEGFID d.o.o., Ljubljana, Slovenia, 2ARDENS d.o.o., Koper,
Slovenia, 3PREMI-LINK d.o.o., Naklo, Slovenia
Jessica Gulinelli,1 Edilson Ferreira,2 Marcos Kuabara,2

Bruno Vieira,2 Renato Andrade,2 Natalia Neiva,2
Ricardo Oliveira2
1
Background: Computer-guided flapless surgical approach is a
method by which one can precisely position implants using

laboratory-fabricated surgical templates acquired from CT
scans without reflecting a flap and merely through the oral
mucosa. The flapless minimally invasive implant surgery has
numerous advantages including better preservation of circulation, soft tissue as well as bone volume at the site. As data
accumulate, dentists are learning that this method shortens
the time of surgery, increases patients comfort, accelerates
healing and allows oral hygiene immediately following surgery. The clinicians are mostly of the opinion that long-term
health and stability of the peri-implant soft tissues is possible
with the presence of adequate soft tissue thickness or
recommended 2.53 mm of keratinized gingival tissue (KGT)
surrounding an implant restoration. A thin gingival biotype
may serve as locus minoris resistentiae for development of
soft tissue defects in the presence of biofilm-induced inflammation or tooth brushing trauma.
Aim: To preserve a deepithelized punched gingival graft
excised during flapless surgery in computer-guided implant
placement and to assess augmentation of KGT and/or localized defect of collapsed alveolar ridge.
Methods: In one female and five male patients, mean age
65.2 9.9 years, eight small horizontal crestal incisions were
Sagrado Coracao University, Bauru, Brazil, 2Imppar

Odontologia, Londrina, Brazil
Background: Maxillary sinus lift procedures with autogenous
bone grafting or synthetic and implant placement have been

extensively documented and reviewed. The residual crestal
bone height as one of the most critical factors influencing
implant survival rate.
Aim: The aim of retrospective investigation was to evaluate
by means of computerized tomographic scans the increase in
height after sinus floor augmentation with different bone
grafting materials and implant clinical success after 2-year follow-up.
Methods: Forty-five patients (24 female, 21 male) aged
between 29 and 84 years-old were undergone maxillary sinus
lift procedures. The cavitieswere filled with particulate bone
autogenous of retromolar area, anorganic bovine bone (Geistlich
Bio-Oss), association of autogenous/anorganic bovine bone or
simultaneous implant placement with sinus lift and anorganic
bovine bone. After 68 months the implants were placed and
measured torque values. The implant survival was defined
when the prosthesis had been delivered and followed for
2 years without infection, pain, or more than 2-mm periimplant bone loss. The computed tomography scans taken before
and 68 months after elevation surgery. The height of bone
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formation was calculated using the Somaris Sienet Magic

View software. The data were analyzed with paired t-test and
non-parametric test (P = 0.05) using the Graph Pad Prism 4.0.
Results: The results showed a statically significant difference
in height after 68 months (P < 0.001), represented by a medium increase of 7.07 mm. A total of 86 fixtures were followed
for more than 2 years after prosthesis delivery. Among the
biomaterials used in the completion of the cavities of patients,
51.2% were autogenous bone, 24.4% anorganic bovine boneand 24.4% association among these two materials. In five
cases the maxillary sinus presented bone septa and in seven
patients simultaneous implant placement withsinus floor elevation. All the implants presented connection of external
hexagon, the medium size of the implants was of 10 mm of
height and the torque medium of insert was of 25 Ncm. One
patient developed sinusitis and two implants were lost. The
2-year survival of fixture was 97.68%.
Conclusions and clinical implications: The height obtained with
the elevation was effective for the installation of the implants
in the maxillary. Both delayed and immediate placement of
implants can be used safely for sinus lifting. There were no
statistically significant differences between the various graft
materials.

Engineering
Computertomography-based evaluation of
volumetric changes after sinus floor
augmentation
Markus Hof, Bernhard Pommer, Michael Girardi,
Patrick Heimel, Georg Watzek, Werner Zechner
Department of Oral Surgery, Bernhard Gottlieb University of
Dentistry, Vienna, Austria
Background: Maxillary sinus floor augmentation through a
lateral approach is the most frequently used method to

increase bone height in the posterior maxilla to allow for
implant placement. However, substantial resorption of autologous bone grafts occurs during healing. Addition of Bio-Oss
granules may reduce graft resorption, thus improving graft
stability.
Aim: The aim of the present study is to assess volumetric
changes of different ratios of grafting material for maxillary
sinus floor augmentation using computed tomographies.
Methods: Postoperative computed tomographies were available
from 31 sinus floor augmentations (25 patients). Computed
tomographies of the maxillary sinuses were obtained postoperatively, after 14 days and 5 months, respectively. Different
ratios of Bio-Oss to autologous bone were used for grafting
through a lateral approach. Volumetric changes of the grafts
were evaluated using the Definiens Developper XD software.
Results: Mean graft volume after 14 days and 5 months was
1.7 cm3 ( 0.8 cm3) and 1.5 cm3 ( 0.8 cm3), respectively.
Based on volumetric measurements of the grafts mean shrinkage was 16%. The volumetric reduction was significantly
234
influenced by the ratio of Bio-Oss and autologous bone

(rs = 0.52, P < 0.001). No influence of age, gender and BioOss particel size was observed.
Conclusions and clinical implications: Within the limits of the
study, the results indicate a significant reduction of graft volume after 5 months of healing. Higher percentages of BioOss resulted in reduced graft shrinkage. However, further
studies are needed to assess the optimized ratio of Bio-Oss
and autogenous bone to achieve long-term graft as well as
implant stability.

Engineering
Semilunar miniblock technique for facial socket

wall preservation
Andriy Huk
Perfect Dent Clinic, Lviv, Ukraine
Background: Prevention of facial bone wall resorption in
postextraction sockets is one of the most challenging tasks

when performing immediate implant placement. Due to some
known biological reasons, socket walls remodel (Araujo 2005)
and this results in loss of alveolar ridge dimensions (Van der
Weiden 2009). This, in turn, leads to flattening of the convex
facial ridge profile even when socket preservation is performed (Fickl et al. 2009, Ten Heggeler 2010) which can cause
aesthetic problems.
Aim: Objective of this study was to evaluate efficiency of preserving facial bone wall after immediate submerged implant
placement into extraction socket utilizing small size semilunar cortical bone blocks.
Methods: The study comprised 10 patients treated with dental
implants placed into fresh postextraction sockets simultaneous with small intraoral block bonegrafts. Implant bed preparation was performed according to common 3D positioning
rules. The cortical bone grafts were harvested with a trephine
bur 3.8, 5 or 6 mm in diameter, which was used to make two
trephine holes in overlapping manner to the depth of 24 mm.
Donor sites were chosen as follows: palatal bone at region of
teeth 1214, base of the alveolar process between teeth 1113
at the facial side, external oblique line, retromolar area. Semilunar cortical grafts were placed inside the socket from vestibular side to the future implant position and facing the buccal
bone. Block stability was obtained by pushing it apically into
the socket using flat osteotome and bone mallet. Due to the
tapered contours of the socket, block became stuck in intimate contact with bone walls. All remaining gaps between
implant and block were filled with autogenous bone chips
mixed with DBBM. A submerged protocol was chosen.
Peri-implant bone level was measured after a healing period of
24 months. Ridge volume at grafted sites was evaluated at
CT scans and itraoperatively during uncovery phase and
compared to preoperative values.
Results: The study involved 12 sockets at maxillary and mandibular premolar and molar sites. No complications were
observed during healing period neither at donor nor at grafted

sights. The buccal bone contour became stable comparing to
initial situation. The mean overall horizontal bone loss after
healing was 0.6 mm. Vertical bone margin became stabilized
at the level of implant shoulder or within 1 mm above it.
Conclusions and clinical implications: Within the limits of this
study, proposed method of socket grafting shows the possibility to eliminate postextraction facial bone changes thus
improving natural view of implant-supported restorations.

Engineering
Bio-Oss and stem cells from bone marrow

obtained from the distal femur for sinus grafting
Juan Carlos Ibanez,1,2 Juaneda Maria Agustina,1,2
Maria Constanza Ibanez,1,2 Martin Ignacio Ibanez2
1
Universidad Catolica de Cordoba, Cordoba, Argentina, 2Private

Practice, Cordoba, Argentina
Background: Sinus grafting has become a common procedure
to obtain adequate height for implant placement in the posterior maxilla. High success or survival implant rate, reduction
of healing time and obtaining a high percentage of vital bone
may be primary objectives when this technique is applied.
Aim: This investigation was design to test if the combination
of grafting material Bio-Oss and bone marrow obtained from
the distal femur with high concentration of stem cells is
capable to be used for sinus grafting obtaining high success/
survival rate and high percentage of vital bone.
Methods: Fifteen sinus grafting procedures were performed in
nine patients. Residual bone width and height was measure.
All the procedures were performed using a lateral approach
with piezo surgery. Ten to 15 cc. of bone marrow with stem
cells was obtained from the distal femur using an appropriate
trocar and aspirate with a syringe without any anti-coagulants.
After eliminate the excess of plasma the bone marrow was
mixed with Bio-Oss (spongiouse large particles) and used to
full fill the space obtained by the elevation of the sinus
mucosae. The lateral window was covered with resorbables
membranes. After 69 months of healing, 31 double acidetched surface implants were placed. RFA analysis was used
to measure initial stability. Six implant sites were created
with 3.5 mm. trephines in order to obtain vertical biopsies for
histological and histomorphometric analyses. After 4
6 months implants were loaded.
Results: All the sinus procedures had an uneventful heal.
Twenty-nine implants were successful and a mean of 38% of
vital bone was obtained at the time of implant placement.
The mean ISQ obtained at implants placement was 62.3 and
60.8 at implant loading
Conclusions and clinical implications: Due the results of this
preliminary report, the use of a mixture of Bio-Oss with
bone marrow obtained from the distal femur seems to be an
efficient combination to obtain an adequate percentage of
vital bone when sinus lifting is performed and for obtaining
good results when implants with microtextured surface are

used.

Engineering
Evaluation of augmented bone over exposed

implants threads, three years follow-up
Atef Ismail
Private Practice, Cairo, Egypt
Background: In implant placement post extraction in most of
the cases diameter of the implant is not coincide with the

existing socket, yielding a space or a gab and most of the cases
need augmentation. Different materials and techniques can be
used to treat such dehiscence or even fenestration. The quality
and the volume of the augmented bone over the exposed
implants threads is a challenge for maintaining soft tissue
support for long time
Aim: Clinical and radiographic evaluation of augmented bone
over exposed implants threads in the treatment of dehiscence
and fenestration.
Methods: Eighteen patient (ten Female, eight Male) indicated
for extraction, indicated for implant therapy. All patients
receive single implant post extraction, yielding horizontal
defect more than two millimeters. All patients received same
type of implants. All exposed threads were counted from the
top of implant to the buccle margin of the bone. All the
exposed threads covered with DUO-TECK membrane using
housing technique. Four months later secondary surgery was
performed including measurements of exposed threads numbers. All patients received X-ray radiographic evaluation at
4 months, 1 year, 2 years, 3 years.
Results: In this study all the defects have horizontal bone
defects more than 2 mm exposed threads from 3 to 9. In this
study all implants were successfully osseointegrated with a
complete coverage of implants threads was seen from 17 to 18
sides. Two cases show bone growth over the covering screw.
One side show from 1 to 2 exposed threads of total eight
threads. Radiographic analysis of augmented bone over
exposed threads evaluated and the mean crestal bone level
change for 1 year was 0.55 0.10 in the first year. Mean marginal bone crestal bone resorbtion of the augmented bone over
the exposed threads is 1.01 mm during the third year.
Conclusions and clinical implications: The results of this clinical study show it is possible to gain bone coverage over the
exposed implants threads by using DUO-TECK membrane.
Augmented bone gain show crestal bone loss at 3 years post
restoration within the commonly accepted measurements.
235

Engineering
Usefulness of alveolar distraction osteogenesis

for dental implant of mandible
Masahiro Iwata, Minoru Murayama, Toshihiro
Nishioka, Yoshihiro Tanimoto, Hiromi Kasai,
Yoko Asai, Akihito Matsuno, Yukihisa Kokuba
Kishiwada tokushukai Hospital, Kishiwada, Japan
Background: Vertical alveolar distraction osteogenesis is an
efficient method for augmentation prior to inserting dental

implants. But a relapse of the transport segment and decrease
in bone height before implant placement is common.
Aim: In this study, we evaluated this alveolar distraction
osteogenesis before implant placement, investigated the
relapse in bone height.
Methods: The subjects were 34 patients, ranged in age from 21
to 65 years with the defect of the mandible (19 males and 15
females). In all cases we treated by vertical alveolar distraction
osteogenesis. Active distraction was started after a latency period of 3 days with a rate of 0.5 mm twice daily. After the end
of alveolar distraction osteogenesis, length of consolidation
was 3 months, and distractors were removed. Bone height was
measured on digital orthopantomographic radiographs, after
distraction and before implant placement.
Results: Mean alveolar distraction was 14.5 mm. The mean
relapse was 19% (13% to 27%) after the end of consolidation.
One month after distractor removal, 10 patients were performed implant placement (Group A). The mean relapse was
5% (17%) at implant placement. On the other hand, 24
patients were performed distractor removal and implant placement at the same time (Group B).
Conclusions and clinical implications: The vertical alveolar distraction osteogenesis before dental implant placement is very
useful but a considerable relapse must be confronted. This
study indicated that implant placement performed at the same
time of distractor removal if possible.

Engineering
Osseointegration of the implants placed in the

reconstructed bone
Shiho Kajihara,1 Kazuya Doi,1 Takayasu Kubo,2
Koji Morita,1 Kazuhiko Hayashi,1 Hiroshi Oue,1
Yasumasa Akagawa1
1
Department of Advanced Prosthodontics, Hiroshima University
Graduate School of Biomedical Sciences, Hiroshima, Japan,

2
Clinic of Oral Implants, Hiroshima University Hospital,
Hiroshima, Japan
Background: When implant fixtures are lost or a large bone
defect locates at implant placement area, it is necessary to
236
apply autogenous bone and artificial bone such as hydroxyapatite (HA) for bone reconstruction. However, the reports of
osseointegration at reconstructed area with HA are few.
Aim: This study evaluated the aspects of osseointegration of
the implants placed in the reconstructed bone by interconnected porous calcium hydroxyapatite (IP-CHA).
Methods: This study design was approved by the Research
Facilities Committee for Laboratory Animal Science at Hiroshima University School of Medicine. Cylinder-type IP-CHAs
(75% porosity, diameter: 4.3 mm, height: 10.0 mm, NEOBONE, Covalent Materials, Japan) as a bone graft material
was placed into eight bone sockets (diameter: 4.3 mm, depth:
10.0 mm) at both sides of the femur of four male HBD Dogs
(weight: 2025 kg). IP-CHA at the left side was a 24-week sample. After 12 weeks of IP-CHA placement, titanium implant
(diameter: 3.3 mm, length: 10.0 mm, Br mark System MkIII
TiUnite, Nobel Biocare, Sweden) was placed into half side of
the IP-CHA at the right femur. (A half portion of the implant
was contacted to the reconstructed IP-CHA and a half of the
femur itself). IP-CHA was also placed into the another bone
socket as a 12-week sample. Implant placement was performed
by Br mark System protocol. After 12 weeks of implant placement, dogs were sacrificed and the bone tissues involved the
implant and or not were obtained. The block without implant
was decalcified and stained with HE. The block with implant
was prepared as undecalcified polishing specimens and stained
with toluidine blue. These samples were examined histologically with a light microscope. The ratio of bone formation at
cortical bone area of the femur was measured histomorphometrically at 12- and 24-week decalcified samples and boneimplant contact (BIC) ratio was measured histomorphometrically at 12-week undecalcified samples.
Results: New bone formation was observed in both of the host
bone and IP-CHA sides. Implant and IP-CHA were integrated
with osseoconduction. Histomorphometrically, new bone formation area was superior in the IP-CHA 24-week sample
rather than IP-CHA 12-week sample. From the BIC ratio,
osseointegration was achieved at the surface between implant
and IP-CHA. Osseointegration was obtained around the
implant in reconstructed bone by IP-CHA.
Conclusions and clinical implications: Based on the limited
results of this study, IP-CHA cylinder might be expected to be
a possible bone graft material to reconstruct bone for implant
placement.

Engineering
Suitability of PEG-membrane combined with

BCP in extensive SFEs
Philip L. Keeve,1 Adrian Lucaciu,1 Anton Friedmann1
1
Department of Periodontology, Witten/Herdecke University,
Witten, Germany
Background: Most recent consensus considers non-resorbable
grafting materials suitable for SFE procedures either used
alone or in combination with autologous bone (AB) particles.

The handling of lateral window for accessing sinus cavity is
under discussion. However, various membranes have been
suggested for covering the access window from lateral before
re-suturing the flap tissue.
Aim: The aim was to observe how the newly introduced in situ
forming polyethylene glycol (PEG-) membrane (MembraGel,
Institut Straumann AG) performed for effectively secluding the
sinus cavity and laterally augmented areas; both grafted by BCP
(Bone Ceramic, Institut Straumann AG) used without AB.
Methods: Three calibrated periodontists from Department of
Periodontology (Witten/Herdecke University) contributed to a
total number of 15 sites in 13 patients. The surgical protocol
was standardized among all patients consisting of two stage
approach; sinus floor elevation combined with a lateral ridge
augmentation followed than by implant placement 69 months
later. SFEs were performed according to original technique by
Tatum (1986). BCP moistured with saline was used exclusively
in all sites being covered by layer of PEG material. After setting
of membrane material a combination of horizontal mattress
and single sutures stabilized the flap margins; tension free adaptation of the flap was achieved by releasing periosteum. Radiographic controls were performed before augmentation and after
healing period prior to implant positioning. Post-augmentation
regimen included pain medication and systemic antibiotics
(Amoxicillin, 1000 mg) and regular mouth rinses (CHX). All
patients were monitored on weekly basis during first month of
healing clinically and photographs taken. Core biopsies were
harvested at implant placement and proceeded histologically.
Results: Soft tissue healing was clinically uneventful without
execeptions. There were non dehiscences and/or membrane
perforations detected. Newly formed hard tissue volume
appeared optimized in vertical and lateral dimensions. Quantity of new mineralized tissue was adequate for placing either
standard or wide body diameter implants (RN or WNI,
Institut Straumann AG). Length of implants used varied from
8 to 12 mm and bone quality was clinically classified as
D1-D2. All surgically created shafts demonstrated adequate
vascularization. In all implants primary stability was
achieved. All implants inserted were well integrated.
Conclusions and clinical implications: Elevating the sinus floor
in presence of 15 mm of residual bone using BCP alone in
combination with synthetic biodegradable membrane for the
lateral window was sufficient to form new bone and to
enhance the alveolar ridge volume for implant placement and
integration in the deficient posterior maxilla.

Engineering
Clinical application of platelet-rich fibrin by the

application of the Double J technique in alveolar
bone defect areas
Su-gwan Kim,1 Jin-son Kim,2 Moon-hwan Jeong,3
Ji-su Oh1
1
Chosun University, Gwangju, Korea, 2Misomore Dental Clinic,
Jeonju, Korea, 3Dallas Dental Clinic, Seoul, Korea

Background: Platelet-rich fibrin (PRF) belongs to a new genera-
tion of platelet concentrates, with simplified processing and

without biochemical blood handling. PRF releases growth factors andmatrix glycoproteins. The Double J technique, which
uses centrifuged venous blood that is sampled using two different types of DB vacutainers, is a procedure that covers the
PRF matrix obtained from one of the DB vacutainers on transplanted osseous coagulum, which is obtained using the plasma
layer and buffering layer from the second DB vacutainer.
Aim: In our study, the Double J technique that uses plateletrich fibrin (PRF) was used to utilize the implant placement in
the alveolar bone defect area.
Methods: The surgical procedure is as follows: (1) Although it
is different depending upon the size of defect areas, generally,
approximately 30 ml of blood is collected. (2) The collected
blood is added to two different types of DB vacutainers. Of the
30 ml of blood, 10 ml of blood is added to a polypropylene DB
vacutainer without silica coating, and 20 ml of blood is added
to two DB vacutainers coated with silica, 10 ml in each. (3)
To balance the center of gravity, another DB vacutainer is prepared containing 10 ml of water. The 4 DB vacutainers are
inserted into a centrifuge (Gyrozen 406G, Republic of Korea).
They are centrifuged at 400 G (or 1750 rpm) for 10 min. The
interval from blood to centrifugation is minimized. (4) After
centrifugation, the plasma layer and the buffy coat layer contained in polypropylene tubes without silica coating is aspirated with syringes and mixed with bone graft materials that
are prepared in advance. After approximately 5 min, coagulants that are suitable to bone graft are formed. (5) The formed
bone graft coagulants are applied to the bone defect areas and
covered with the PRF matrix (Fig. 3), and a primary suture
without tension is placed.
Results: When the technique was utilized with the implant
placement in the alveolar bone defect area, good results were
obtained.
Conclusions and clinical implications: It is thought that PRF is
a very useful material for the restoration of alveolar bone
defects that are commonly detected at the time of the implant
placement in edentulous areas.
Acknowledgment: This study was supported by a grant of the
Korea Healthcare technology R&D Project, Ministry for
Health, Welfare & Family Affairs, Republic of Korea.
(A091220).
237

Engineering
BMP2-delivering heparinized-titanium implant

with enhanced antibacterial activity and
osteointegration
Deok-won Lee, Tae-hee Kim
Kangdong Gu, Seoul, Korea
Background: Insufficient bonding of implants to bone tissues
and bacterial infections lead to the failure of titanium (Ti)based orthopedic and dental implants.
Aim: The aim of this study is to develop novel Ti implants
that enhance osteoblast functions, while simultaneously
decreasing bacterial infections.
Methods: First, the surface of pristine Ti was functionalized
with heparin-dopamine by mimicking a mussel adhesion
mechanism. Gentamicin sulfate (GS) and/or bone morphogenic protein-2 (BMP-2) was then sequentially immobilized to
the heparinized-Ti (Hep-Ti) surface. The compositions of pristine Ti and Hep-Ti with or without gentamicin and/or BMP-2
were characterized by X-ray photoelectron spectroscopy (XPS)
and the growth of Staphylococcus aureus on the substrates
was assayed. Osteoblast functions of all Ti substrates were
investigated by cell proliferation assays, alkaline phosphatase
(ALP) activity, and calcium deposition.
Results: The results showed that the growth of bacteria on
GS/Hep-Ti and GS/BMP-2/Hep-Ti was significantly lower
compared to that on the pristine Ti and BMP-2/Hep-Ti. In
addition, BMP-2/Hep-Ti and GS/BMP-2/Hep-Ti significantly
enhanced ALP activity and calcium mineral deposition of
osteoblast cells. Taken together, GS/BMP-2/Hep-Ti could
achieve the dual functions of excellent antibacterial activity
and osteoblast function promotion.
Conclusions and clinical implications: Therefore, dual drug
(antibiotics and osteoinductive protein)-eluting Ti substrates
such as GS/BMP-2/Hep-Ti are a promising material for the
enhanced osteointegration and implant longevity in orthopedics and dentistry.
body bone graft offer several advantages such as making intraoral approach possible for surgical access, facilitating the clinician to operate in the same field as the recipient site, low
resorption rate and short healing period due to its cortical
characteristics, needless of horizontal osteotomy near the root
apex, less risk of nerve injury.
Aim: The aim of this study was to evaluate the morphology of
atrophic mandible using Cone-Beam Computed Tomography
(CBCT) for mandibular body bone (MBB) graft and to purpose the
usefulness of MBB as a good donor site for autogenous bone graft.
Methods: The subjects consisted of 26 patients undergoing
mandibular body bone graft in atrophic mandible (n = 26).
Using cross-sectional computed tomography (CT) images, the
distance of alveolar bone width, the distance from mandibular
canal to alveolar crest, the thickness of buccal cortical bone
and the distance from mandibular canal to buccal cortical
bone were measured at the premolar (PM), the first molar
(M1), the second molar (M2) and anterior border of ramus
(RM) of edentulous mandible.
Results: Average alveolar bone width were 6.25 mm (PM),
6.7 mm (M1), 7.51 mm (M2), 10.98 mm (RM). average alveolar
bone height were 13.26 mm (PM), 12.67 mm (M1), 11.26 mm
(M2), 10.82 mm (RM). Cortical bone thickness were 1.96 mm
(PM), 2.29 mm (M1), 2.51 mm (M2), 2.59 mm (RM). Distance
from the mandibular canal to buccal cortical bone were
2.50 mm (PM), 4.31 mm (M1), 5.51 mm (M2), 6.28 mm (RM).
Conclusions and clinical implications: A 2.0 mm thickness and
from the first molar to the second molar about 20~25 mm
buccal cortical bone could be harvested at atrophic mandible.
Atrophic mandibular body bone graft is a safe technique and a
good donor site. Based on the results of the present study, surgeon can gain sufficient amount of cortical bone required for
bone graft, in spite of the patients atrophic stage of mandible.
In addition, by calculating the distance from the nerve canal
using pre-operative CBCT data and 3-D imaging program, the
safety of surgical procedure can be improved especially using
mandibular body bone graft or ramal graft.

Engineering

Engineering
Maxillary sinus floor augmentation procedure:

Summers vs. a piezo-electric technique.
Morphologic analysis using Cone-Beam CT and

3D program in atrophic mandible for mandibular
body bone graft
Robert Kirmeier,1 Michael Payer,1 Susanne Platzer,2

Nicola Bianco,1 Sebastian Kuhl,1,3 Andreas Weiglein,4
Norbert Jakse1
Department of Oral Surgery and Radiology, School of Dentistry,
Jae-yeol Lee, Jung-han Lee, Young-chae Noh,

Yong-deok Kim,1 Jung-bo Huh2
Medical University Graz, Graz, Austria, 2Department of
Graz, Austria, 3Clinic for Oral Surgery, Radiology, and Oral
Department of OMFS, School of Dentistry, Pusan National

2
Prosthodontics, School of Dentistry, Medical University Graz,
University, Yangsan, Korea, Department of Prothodontics,
Medicine, School of Dental Medicine University of Basel, Basel,
Yangsan, Korea
Switzerland, 4Institute of Anatomy, School of Dentistry, Medical

University Graz, Graz, Austria
Background: The donor sites mainly used as a source of autog-
enous bone graft include mandibular symphysis, ramus, mandibular body, etc. Among these donor materials, mandibular
238
Background: Sinus floor augmentation of the lateral maxilla is
a highly predictable and successful procedure. To increase
bone volume prior to implant placement, different transcrestal

techniques can be used.
Aim: This cadaver-based study was designed to compare the
performance of hand instruments (Summers technique) vs.
piezoelectric devices (Sinus Physiolift Mectron SpA, Carasco,
Italy).
Methods: Out of a number of 80 cadaver heads in Thiels fixation 16 undamaged and edentulous objects were selected for
computer tomographic scans. Schneiderian membrane elevation was carried using either piezosurgery or conventional
hand instrumentation, which was assigned by lot. After simulation of sinus augmentation by the use of a radiopaque
impression material (elite implant medium, Zhermack, Italy),
a postoperative scan was carried out. All scans were processed
with computed tomography (Somatom plus 4, Siemens AG,
Bensheim, Germany). In three replicates a validated computer
software (Voxim, IVS Technology GmbH, Chemnitz, Germany)
was used to calculate augmentation volumes. Accuracy and
reliability of the volume measurements were assessed based
on the intra-class correlation coefficient. The non-parametric
MannWhitney U-test was applied to calculate the differences
in augmented volume between the two methods. A P
value < 0.05 was considered to indicate statistical significance.
Results: An intra-class correlation coefficient of 0.99 indicated
a close to perfect agreement of the volumetric quantification.
A mean graft volume of 0.29 0.18 cm3 (0.07 0.60 cm3) was
measured for the Summers technique compared to 0.39 0.32
cm3 (0.05 1.04 cm3) for the Sinus Physiolift technique.
There is no significant difference in regards to trauma to the
Schneiderian membrane or augmented volume.
Conclusions and clinical implications: Both techniques generate
expedient augmentation volume in the posterior atrophic maxilla. The piezoelectric technique can be recommended as an
alternative tool to graft the floor of human maxillary sinuses.
and to evaluate the reproducibility of the measurement

method.
Methods: Twenty-six partially or totally edentulous patients
with insufficient alveolar ridge width, treated either with
fresh-frozen allogeneic bone (AL) or autologous bone (AT)
onlay block grafts prior to implant placement (13 patients
with 19 block grafts in each group), were included in this analysis. Two masked examiners measured (in duplicate 2 weeks
apart) the alveolar ridge area on 2-D CBCT images of the
grafted regions, recorded prior to surgery and 14 days (14 d)
and 6 months (6 m) after grafting. Differences in alveolar ridge
area among the various observation times were evaluated
using repeated measures ANOVA followed by Tukeys test,
and differences between tested graft materials using t-tests.
The inter- and intra-observer reproducibility was assessed
through Pearson correlation tests.
Results: Inter- and intra-observer reproducibility was high,
with no statistically significant differences between observers
or duplicate measurements. Significant increase in alveolar
ridge dimensions, allowing implant placement, was obtained
with both types of grafts 6 m after grafting; no significant
differences in alveolar ridge area were observed between the
groups at the various observation times. However, graft
resorption in the AL group was significantly larger compared
to that in the AT group at 6 m (P = 0.04).
Conclusions and clinical implications: Although similar
amounts of alveolar ridge width were observed in the two
groups, significantly largerbone graft resorption was seen in
patients treated with fresh-frozen allogeneic bone than in
those treated with autologous bone 6 months following alveolar ridge augmentation. Planimetric measurements of alveolar
ridge on CBCT images showed high reproducibility.

Engineering
Transposition of tongue pedicle flap before

implantation at resected mandible due to tumour
Autologous and fresh-frozen allogeneic block

bone grafts. A CBCT analysis
Tine Kjrgaard,1 Ccilie Basse Eriksen,1
Rubens Spin-neto,1 Elcio Marcantonio Jr,3 Andreas
Stavropoulos,2,4 Ann Wenzel1
1
Health, Department of Dentistry, Oral Radiology, Aarhus
University, Aarhus, Denmark, 2Health, Department of Dentistry,

Aarhus University, Aarhus, Denmark, 3UNESP Univ. Estadual
Paulista, Araraquara, Brazil, 4CEPBR Center for Experimental
and Preclinical Biomedical Research, Athens, Greece
Background: Cone Beam Computerized Tomography (CBCT)
may potentially be an efficient tool to evaluate the treatment

outcome after grafting procedures.
Aim: To estimate dimensional changes in autologous and
fresh-frozen allogeneic block bone grafts 6 months after alveolar ridge augmentation by means of CBCT (i-CAT Classic),

Engineering
Kocar Miha
Department of Maxillofacial and Oral Surgery, University
Clinical Center Ljubljana, Ljubljana, Slovenia
Background: Tongue pedicle flap (TPF) is known for recon-
struction after intraoral resection of squamous cell cancer and

underlying bone. A lot of times all teeth are removed during
primary resection due to location of primary tumour, caries
lesion of them or consequently radiotherapy. After curing primary disease for better rehabilitation good chewing function is
obligatory due to correct nutrition. TPF has not keratinized
mucosa what is unfavourable for tissue around implants
which supported prosthetics.
Aim: Aim of this pilot study is presentation of protocol for
preparing favourable soft tissue before implantation after primary operation and reconstruction with TPF in mandible.
Methods: Four consecutive patients (1 female/3 male), mean
age was 54 years (ranging 5255) were reconstructed with TPF
239
at the time of removing carcinoma. Two also got radiotherapy

due to protocol. Three had fully edentulous mandibles where
residual alveolar processes were covered with mobile mucosa,
lover vestibules were totally flat. Partial edentulous patient
had same clinical problems. Irradiated patients got hyperbaricoxygen therapy due to protocol before intervention. Vestibuloplasty in all mandibles were performed. Insertion of genioglossus and geniohyoideus on mandible was detached and fixed
with trans-cutaneous suture over gauze tampon in submental
area. Mucosa was dissected supra-periosteal, adjusted down
and sutured on periosteal. On stripped alveolar process prefabricated acrylic plate was fixed with titanium screws. Wound
was healing by second intention under antibiotic therapy and
mouth hygiene was controlled with rinsing of iodine solution.
Sutures, acrylic plates were removed after 4 weeks. Two-stage
implants (2/2/4/4) were inserted 6 weeks after vestibuloplasty,
in one case temporization was done on four splinted implants.
Reopening was done at other three patients (2/2/4) after
4 months. Prosthetics removing/fixed (3/1) were delivered at
all patients by protocol after that period. Clinical control was
done every 3 months. X-rays were performed every year.
Results: In all cases favourable soft tissue conditions were
observed without disturbance of tongue movement. All
implants were integrated uneventfully in bone. Clinically
mucosa was less mobile, vestibules got better anatomical
appearance. Tissues around implants were stable with no
inflammation in 2-year period.
Conclusions and clinical implications: Combine of vestibuloplasty with prefabricated acrylic plate and transposition of genioglossus and geniohyoideus insertion gave us better soft tissue
condition before implantation at patients who were surgically
treated due to oral carcinoma and reconstruction with TPF.
Due to small sample investigation should be prolonged and
further histological investigation should be done on new
formed mucosa.

Engineering
Bone substitute plus enamel matrix derivative vs.

autogenous bone in deep-wide intrabony defects:
a pilot study
Stephane Korngold,1,2 Stephane Kerner,1,2
David Nisand,2 Philippe Bouchard1
1
Rothschild Hospital, Paris, France, Private Practice, Paris,
Aim: To compare the efficacy and safety of the combination of
a synthetic bone graft substitute (Straumann BoneCeramic)

and an enamel matrix derivative gel (Straumann Emdogain) vs.
autogenous bone graft alone (used as control) in the treatment
of deep-wide periodontal intrabony defects.
Methods: In this prospective, randomized, two-arm controlled
study, 18 consecutive patients with moderate to severe periodontitis were enrolled. Experimental teeth were mandibular
molars, maxillary or mandibular premolars and canines exhibiting a probing depth 5 mm with 1 or 2-wall morphology (at
least 2/3 of the defect). The depth of the intrabony defect was
at least 3 mm with an angle 25 as measured on radiographs. The surgical technique was the same for both test and
control groups. In the control group the bone was harvested at
the ramus using the K-systemTM. Changein CAL measured at
six sites of the treated tooth between baseline and 12 months
was used to compare the two treatments. A difference of
1 mm between the treatment groups was regarded as noninferiority (CI95%). Secondary variables included PPD reduction and radiographic bone gain. Bone level was measured by
ImageJ.
Results: Ten patients (test) and eight patients (control) were
analyzed (mean age: 34.2 + /- 8.5 years, gender ratio M/F: 7/11).
The non-inferiority of the two treatments wasconfirmed by
the CI95% for CAL that ranged from 0.995 to 0.536 mm. The
mean gain in CAL observed 12 months postoperatively was
1.00 0.81 mm for the test group and 0.77 0.70 mm for the
control group, respectively. No significant differences were
found for PD and bone level gain.
Conclusions and clinical implications: The present data show
that a combination of a synthetic bone graft substitute and
enamel matrix derivative gel may improve the CAL gain as
well as autogenous bone graft in deep-wide periodontal intrabony defects.

Engineering
Osteocyte lacunar density and area in newly

formed bone of the augmented sinus
Ulrike Kuchler,1,2,3 Gerd Pfingstner,2 Dieter
Busenlechner,2,3 Toni Dobsak,2,3,4 Karoline Reich,2,3,4
Patrick Heimel,2,3,4 Reinhard Gruber1,2,3
1
Department of Oral Surgery and Stomatology, School of Dental
Medicine, University of Bern, Bern, Switzerland, 2Department of
France
Oral Surgery, School of Dental Medicine, Medical University of
Background: The use of autogenous bone graft results in a sig-
Vienna, Vienna, Austria, 3Austrian Cluster for Tissue

Regeneration, Vienna, Austria, 4Karl Donath Laboratory for Hard
nificantly greater change in bone level and attachment level

than open flap debridement procedures. The use of enamel
matrix derivative may improve clinical attachment level
(CAL) gain and probing pocket depth (PPD) reduction. A significant association between radiographic defect angle and
CAL gain has been shown. The use of bone grafting in the
treatment of deep-wide intrabony defects has been suggested
to avoid the collapse of the flap.
240
Tissue and Biomaterial Research, Department of Oral Surgery,

Medical University of Vienna, Vienna, Austria
Background: Osteocytes, the most common cells of the bone
are buried in lacunae. Density and area of the osteocyte lacunae changes with increasing maturation of the newly formed
bone. Evaluation of osteocyte lacunae can therefore provide
insights into the process of graft consolidation.
Aim: In the present study, we re-evaluated histological speci-

Engineering
materials. Right and left sides were grafted with tooth-derived

materials and synthetic hydroxyapatite, respectively. Toothderived materials were made of respective autogenous teeth
extracted 8 weeks before. The whole teeth were prepared into
powder form through crushing, demineralization, defatting,
freeze-drying and sterilization. All miniature pigs were sacrificed at 12 weeks after bone graft which was known to be a 1
sigma (r) period for pigs. Specimens were histologically evaluated under light microscope after Haematoxylin-eosin staining
followed by the semi-quantitative study via histomorphometric analysis. Percentage of new bone over total area was evaluated using digital software for area calculation.
Results: All specimens were available but one in the right side
(experimental group) which was missing during specimen
preparation. The study demonstrated new bone at the periphery of the existing bone on both groups showing the evidence
of bone remodelling. But it was only in the autogenous toothderived bone group (experimental group) that new bone was
encroaching on the central part of the graft at the 1 sigma (r)
period. Histomorphometric analysis showed more new bone
formation on the experimental group compared to control
group. Although without statistical significance (P > 0.05),
mean percentage area for new bone were 57.19 11.16% and
34.07 13.09% for experimental and control groups, respectively.
Conclusions and clinical implications: The novel bone graft
material using autogenous tooth is superior to synthetic
hydroxyapatite bone graft materials in this semi-quantitative
study. This new augmentation material is basically safe
because it is of autogenous origin and what is more, it will
reduce donor site morbidity. Conclusively, the safety and
efficacy of this new material will help dentists in planning
dental treatment in areas of poor bone quality such as posterior maxillary edentulous ridge.
Autogenous tooth-derived material results in

successful minipig sinus augmentation

Engineering
mens, 6 and 12 weeks after the sinus of minipigs was augmented with Bio-Oss, a deproteinized bovine bone mineral,
and Ostim (Chris Arts et al. 2006), an aqueous paste of synthetic nanoparticular hydroxyapatite (Busenlechner et al.
2009). The two bone substitutes show a different degradation
profile. This study is based on the assumption that osteocyte
lacunar density and area decreases with the maturation of
newly formed bone in the augmented site.
Methods: Here we determined the osteocyte lacunar density
and the osteocyte lacunar area in histological specimens, 6
and 12 weeks after the sinus of minipigs was augmented with
Bio-Oss, a deproteinized bovine bone mineral, and Ostim,
an aqueous paste of synthetic nanoparticular hydroxyapatite.
The region of interest was defined by the following criteria: (1)
>1 mm from the host bone, (2) >0.5 mm from the sinus
mucosa, (3) minimum area of 0.2 mm2, and (4) bone tissue
spanning at least two bone substitute particles.
Results: The osteocyte lacunar density significantly decreased
within the observation period in the Bio-Oss group and in
the Ostim group. The lacunar area distribution was similar
between the Bio-Oss group at 6 weeks and the Ostim
groups at 6 and 12 weeks. A more narrow distribution towards
a lower lacunar area was observed in the Bio-Oss group at
12 weeks.
Conclusions and clinical implications: These results suggest
that the osteocyte lacunar density and the area decrease in the
newly formed bone within the augmented sinus in this particular model situation. These measures provide insights into
the maturation of the newly formed bone in the augmented
sinus.
Jeong Keun Lee,1 Du Han Lee,1 Young Kyun Kim,2

Kyung Wook Kim,3 In Woong Um4
1
Ajou University School of Medicine, Suwon, Korea, Seoul
National University Bundang Hospital, Seoul, Korea, 3Dankook

University College of Dentistry, Chonan, Korea, 4In Private
Clinic, Seoul, Korea
Sinus augmentation with BMP-2 coated synthetic

bone substitute in rabbits
Kyu An Lee, Youna Choi, Jung-seok Lee, Jung-chul
Park, Chang-sung Kim, Seong-ho Choi, Kyoo-sung
Cho, Jung-kiu Chai, Ui-won Jung
Department of Periodontology, Research Institute for Periodontal
Background: Development of a new augmentation material
Regeneration, College of Dentistry, Yonsei University, Seoul,
which would prevent infectious episode of non-self origin, but

still retains the capacity of autogenous graft materials. The
concept of autoinduction (Urist 1965) and ossification by dentin matrix (Yeomans and Urist 1967) inspired the authors into
tooth-derived bone graft material of self origin.
Aim: The aim of this study was to elucidate the effectiveness
of the autogenous tooth-derived bone materials by experimental study using miniature pigs maxillary sinus graft via histologic analysis.
Methods: Five 18-to-24-months old male miniature pigs were
selected and maxillary sinuses were grafted with bone graft
Korea
Background: Absorbable collagen sponge is available as an
approved carrier system for recombinant human bone morphogenetic protein-2 (rhBMP-2) for maxillofacial indications.
However, its rapid resorption rate and lack of structural durability might be inappropriate for maxillary sinus augmentation. Biphasic calcium phosphate (BCP), which is a synthetic
bone substitute, could be an alternative carrier system for
better space maintenance against pneumatization.
241
Aim: The aim of this study was to evaluate the osteoinduc-
Aim: The objective of this study was to elucidate the healing
tive effect of rhBMP-2 coated BCP carrier system in rabbit

sinus model.
Methods: A total of 16 maxillary sinuses in eight male rabbits
was used to compare rhBMP coated BCP as the test group and
BCP alone as the control group. RhBMP-2 coated BCP was prepared by adding rhBMP-2 solution (0.67 ml in 1.5 mg/ml buffer) to 1 g of BCP granule and lyophilized in a freezer-drier.
The same amount of rhBMP coated BCP and BCP alone were
bilaterally grafted at the maxillary sinuses, respectively. The
animals were sacrificed 2 and 8 weeks postoperatively. Radiographic and histological analyses were performed.
Results: The augmented volume was statistically larger in the
test group than the control in 2 weeks. In histological finding
of 2 weeks, healing pattern of each group was different,
although there was histometrically no significant difference in
new bone. A seam of new bone was lining the reflected sinus
membrane, but most of grafted particles were encapsulated by
fibrous tissue in the test group. On the other hand, new bone
sprouted from the parent bone and bony window area in the
control. In 8 weeks, both groups showed similar bone formation.
Conclusions and clinical implications: Within the limitation of
the study, it can be concluded that rhBMP-2 can stimulate the
osteoinductive potential of the sinus membrane at the early
stage of healing, although there was no significant superiority
in bone formation.
process involved in the incorporation of the biomaterials with

different biodegradation patterns following grafting of the fresh
extraction socket.
Methods: Third premolars in four quadrants of eight beagle
dogs were extracted and randomly treated with either one of
hydroxyapatite (HA), biphasic calcium phosphate (BCP),
b-tricalcium phosphate (b-TCP) or no graft (C). Histologic
observations and histomorphometric analysis at three zones
(apical, middle and coronal) of the socket were done. Socket
area (S) and the proportions of newly formed bone (% NB),
residual biomaterials (% RB) and provisional matrix/marrow
space (% PCT) at 2, 4 and 8 weeks were measured. The numbers of osteoclast-like multinucleated cells (No.OC) were also
counted for three different zones.
Results: % NB was higher in control group compared to the
grafted groups for all healing periods.%NB of HA and BCP
increased with time periods, but the% RB showed different patterns that decrease in BCP occurred while rare change in HA.%
NB of b-TCP showed smallest portion compared to other grafted
groups at 2 and 4 weeks, however increased in excess at
8 weeks.% RB of b-TCP was less than HA and BCP for all healing periods. Numbers of multinucleated cells were higher in
BCP and b-TCP followed by HA and smallest in control group.
Conclusions and clinical implications: Within the limit of this
study, grafted biomaterials delayed bone formation of the
extraction socket, and different healing process was driven
according to the biodegradation patterns of biomaterials.
These histologic results can provide the evidence for the selection of biomaterials in socket preservation and immediate
implantation.

Engineering
Biomaterials with various biodegradation

patterns in extraction socket: a histometric
in vivo study

Engineering
Jung-seok Lee,1 Ji-youn Hong,2 Seong-ho Choi,1

Eun-kyoung Pang,2 Ui-won Jung,1 Chang-sung Kim,1
Kyoo-sung Cho,1 Chong-kwan Kim3
Socket grafting using b-tricalcium phosphate in a

hydroxyl sulphate matrix
Department of Periodontology, Research Institute for Periodontal
Regeneration, Yonsei University College of Dentistry, Seoul,

Korea, 2Department of Periodontology, Graduate School of
3
Minas Leventis,1 Orestis Vasiliadis,1 Nadia Theologielygidakis,1 Peter Fairbairn,2 Ioannis Iatrou1
1
Department of Oral and Maxillofacial Surgery, Dental School,
Medicine, Ewha Womans University, Seoul, Korea, Department
University of Athens, Athens, Greece, 2Private Practice, London,
of Periodontology, Research Center of Orofacial Hard Tissue
United Kingdom
Regeneration
MRC
, Yonsei University College of Dentistry, Seoul,
Korea
Background: Dimensional alterations of extraction socket is
well demonstrated, and some studies found that placement of

biomaterials in extraction socket modified marginal ridge
alteration of the socket. However, slowly resorbing biomaterials like bovine hydroxyapatite remained all over the defect
area even at 2 and 3 months after graft and seemed to alter
the healing process in coronal area of the socket. Whereas, fast
resorbing biomaterials like autogenous bone and tricalcium
phosphate had been mostly resorbed before the time that new
bone formation would occur at coronal area, and these resorption rates could affect the process of socket healing.
242
Background: Studies in humans and animals have shown that
following tooth extraction, the alveolar bone becomes markedly reduced as a result of resorption of the edentulous ridge.
This can negatively influence bone volume that is needed for
future implant placement. It is suggested that the ridge dimensions can be preserved by socket grafting at the time of tooth
extraction with the use of various bone graft substitutes.
Aim: To evaluate the clinical efficacy of a biphasic synthetic
bone grafting material consisting of b-tricalcium phosphate in
a hydroxyl sulphate matrix for socket preservation and
implant integration at the post-extraction site.
Methods: In 4 of a series of 10 patients, requiring extraction of
a posterior tooth of the mandible or the maxilla, b-tricalcium
phosphate in a hydroxyl sulphate matrix (Fortoss VITAL, Biocomposites, Etruria, Stoke-on-Trent, England) was utilized as
a grafting material for socket preservation using the Bio-Col
technique. The horizontal ridge dimensions were measured
after tooth extraction and at implant placement after
3 months. Bone core biopsies were obtained prior to implant
placement for histologic, histomorphometric and microcomputed tomography analysis. Primary implant stability was
evaluated by resonance frequency analysis (Osstell ISQTM,
Goteborg, Sweden).
Results: Analysis of the data showed that b-tricalcium phosphate in a hydroxyl sulphate matrix preserved adequately the
width of the alveolar ridge 3 months after tooth extraction.
Histologic, histomorphometric and microcomputed tomography analysisrevealed pronounced bone regeneration and resonance frequency analysis showed high ISQ levels at implant
placement.
Conclusions and clinical implications: The preliminary results
of this clinical study showed that b-tricalcium phosphate in a
hydroxyl sulphate matrix can be used successfully as a grafting material for socket preservation prior to implant placement. The completion of all cases with detailed evaluation of
all results, the statistical analysis of the data and the comparison with other grafting materials will complete this prospective study in the near future.
botissdental GmbH, Berlin, Germany) or resorbable membranes (Jason membrane, botissdental GmbH, Berlin, Germany) for ridge preservation and augmentation prior to
implant placement. Minimally invasive protocols were followed in all cases. Bone regeneration and site preservation/
augmentation was evaluated clinically and radiographically
with plain radiographs and/or cone-beam computed tomography prior to tooth extraction, at implant placement and after
prosthetic restoration.
Results: Bone grafting materials such as allografts or alloplasts
that induce a high local turnover of new bone formation and
graft resorption produced excellent results in preserving the
sites where implants were placed in a second stage. Xenografts
that are characterized by slow resorption and fast integration
by the new-formed bone gave excellent results in augmenting
the residual ridges bucally in areas adjacent to implant sites
where dimensional stability is important.
Conclusions and clinical implications: The presented cases
highlight the use of specific regenerative materials to preserve
the alveolar ridge after tooth extraction and augment the bone
prior to implant placement in order to achieve optimal results
following minimal invasive surgical protocols.

Engineering
Effects of adipose-derived stem cells on bone

healing and mineralization in calvarial defects in
type 2 diabetic rats
Ridge preservation and augmentation using bone

graft substitutes: case series
Lihua Liang, Yingliang Song

Engineering
Department of Implant Dentistry, School of Stomatology, Fourth
Minas Leventis, Orestis Vasiliadis, Nadia Theologielygidakis, Ioannis Iatrou
Military Medical University, Xian, China
Department of Oral and Maxillofacial Surgery, Dental School,
Background: The number of type 2 diabetes mellitus (T2DM)
University of Athens, Athens, Greece
individuals required dental implants is increasing. Unfortunately, clinical studies have revealed T2DM patients have
higher implant and bone grafting failure rates than the general
population, likely due to inferior bone healing. A tissue engineering technique based on adipose-derived stem cells (ASCs)
with proven capacity to differentiate along osteogenic lineages
has long been used to promote bone regeneration in bone
defects in healthy anmimals and humans.
Aim: We sought to investigate whether ASCs combined
withanorganic bovine bone (Bio-Oss) improve bone repair and
mineralization in calvarial critical-sized defects (CSD) in
T2DM rats.
Methods: High-fat diet (4 weeks) with a low-dose of streptozotocin (30 mg/kg) was used to induce a T2DM model. ASCs
were harvested from inguinal fat pads of healthy SD rats.
Calvarial CSDs (d = 5 mm) in T2DM rats (four groups, n = 12)
were prepared and randomly filled with Bio-Oss alone or BioOss seeded with 3 9 105, 3 9 106 or 3 9 107 ASCs/graft. Specimens were assayed using micro-CT, energy disperse spectroscopy (EDS) and histomorphometry at 4 and 8 weeks postimplantation. The statistic analysis of two-way classification
ANOVA was used.
Background: Many studies have shown that preservation and
augmentation of the alveolar socket at the time of tooth

extraction is the most predictable way to preserve the dimensions of the residual ridge. The materials and surgical techniques in use today facilitate bone preservation and
augmentation prior to implant placement and enable clinicians to more predictably ensure the functional and esthetic
outcomes of the implants and subsequent restorations that are
delivered.
Aim: To evaluate clinically and radiologically the efficacy of
various bone graft substitutes in preserving and augmenting
post-extraction sites using minimally invasive surgical techniques.
Methods: In adult patients requiring tooth extraction due to
trauma, periodontal disease or failed endodontic therapy
allografts (maxgraft, botissdental GmbH, Berlin, Germany),
alloplasts (maxresorb and maxresorb inject, botissdental
GmbH, Berlin, Germany) or xenografts (cerabone, botissdental GmbH, Berlin, Germany) were used alone or in combination with wound dressing materials (Jason collagen fleece,
243
Results: For micro-CT measurements, bone surface/bone vol-
ume, rabecular thickness and trabecular number were the

highest and trabecular spacing was the lowest in the 3 9 106
group at 8 weeks. They were not statistically significant
between the 3 9 106 and 3 9 107 groups (P > 0.05). The Ca/P
ratio measured by EDS was higher in the control group compared with the 3 9 105 group (P = 0.000), and the latter ratio
was lower than the 3 9 106 and 3 9 107 groups (P = 0.012,
P = 0.000), though the Ca/P ratios were not significant among
control, 3 9 106 and 3 9 107 groups (P > 0.05). The results
showed that new bone and the degree of mineralization were
improved in the 3 9 106 group at 8 weeks. The Histological
results revealed new bone and the partial remodeled Bio-OSS
scaffolds in CSDs appeared fusion or bridge in the experimental groups but minimal new bone in the control group.
Conclusions and clinical implications: ASCs also enhanced
bone healing and mineralization in calvarial defects in T2DM
rats, when used in association with Bio-Oss scaffolds, and a
concentration of 3 9 106 ASCs/graft chosen was the optimal
dose. Our findings suggest that a combination of ASCs and
Bio-Oss scaffolds can advance adequate bone quantity and
quality for dental implants. We believe these results have
implications in the successful rates of bone grafting and dental
implants in DM patients with missing teeth.

Engineering
Custom-made porous hydroxyapatite scaffolds for

alveolar ridge augmentation
Francesco Mangano,1 Piero Zecca,1 Samuele Pozzi,1
Aldo Macchi,1 Michele Figliuzzi,2 Jamil Shibli,3 Carlo
Mangano1
1
Dental School, University of Varese, Varese, Italy, 2Dental
School, University of Catanzaro, Catanzaro, Italy, 3Dental

School, University of Guarulhos, Guarulhos, Sao Paulo, Brazil
Background: Rehabilitation of partially or totally edentulous
patients with implant-supported restorations has become a

common practice in the last few decades, with reliable longterm results. However, due to the frequency of localized or
generalized bone defects of the alveolar ridge, as a result of
atrophy, dental trauma, extractions or periodontal disease, a
previous phase of reconstructive surgery is needed to regenerate such defects. Different approaches and materials have been
proposed for the treatment of deficient alveolar ridges, such as
onlay grafts, interpositional grafts and guided bone regeneration. Although it has been shown that it is possible to augment bone with all these techniques, the number of
complications and failures of these procedures is still high. In
the last few years, considerable progress has been made in the
development of computer-aided-designing/ computer-aidedmanufacturing (CAD/CAM) techniques. The main advantage
of these techniques is their ability to fabricate complex products directly from a computer model. More recently, attempts
have been made to fabricate custom-made scaffolds, allowing
244
bone grafts to be tailored for specific applications or even for

individual patients, using computer-assisted methods.
Aim: This study describes a new computer-aided-designing/
computer-aided-manufacturing (CAD/CAM) method to fabricate custom-made porous hydroxyapatite (HA) scaffolds for
alveolar bone augmentation, to allow implant placement.
Methods: Computed tomographic (CT) images of the atrophic
alveolar ridges of six patients (three males and three females,
aged between 4556 years) were acquired and modified into
three-dimensional (3D) reconstruction models. These models
were transferred as stereolithographic files (STL) to a computeraided-designing (CAD) program, where a virtual 3D reconstruction of the alveolar ridge was performed, drawing anatomicallyshaped, custom-made scaffolds. A computer-aided-manufacturing (CAM) software generated a set of tool-paths for manufacture on a computer-numerical-control (CNC) milling machine
into the exact shape of the reconstruction, and anatomicallyshaped, custom-made hydroxyapatite scaffolds (Biocoral, Leader-Novaxa, Milan, Italy) were obtained.
Results: The anatomically-shaped, custom-made scaffolds well
matched the shape of thebone defects and were easily
implanted during surgery. This matching of the shape helped
to reduce the time for the operation and contributed to the
good healing of the defects. After a 6-month healing period, a
well-formed bone was clinically available to allow a correct
implant placement.
Conclusions and clinical implications: Although this is an
interim report, this preliminary data show promising results,
mainly for alveolar ridge augmentation.

Engineering
Block graft of a-TCP with silicon in rabbits

critical defects
Jose Eduardo Mate-sanchezDe Val,1 Mara Piedad
Ramnirez-fernandez,1 Jose Luis Calvo-guirado,1 Rafael
Arcesio Delgado-ruz,1 Bruno Negri,1 Laura Lopezmar,1 Cristina Calabria-zapata,1 Guillermo Pardozamora,1 Isabel Mara Martnez,2 Piedad NievesDe
Aza2
1
Murcia University, Murcia, Spain, 2Elche University, Elche,
Spain
Background: Bioceramics, especially calcium phosphate ceram-
ics, have been widely used for bone tissue repair in orthopedic
and dental applications due to their good biocompatibility and
osteoconductivity. The possibility of adding osteoinductive
bioactive components that allow greater integration of the
block, preventing its loss and encapsulation, has become
another focus of recent study. The addition of silicon to TCP
can improve stability, provide better structural properties and
stimulate new bone formation.
Aim: The aim of this research, therefore, was to investigate
whether new blocks of TCPss with different concentrations of
Si stimulate bone deposition on their surfaces, coupled with
osteoclastic cell resorption and/or biodegradation when

implanted into critical size defects (6 mm ) in rabbit tibiae,
comparing this material with synthetic pure a-TCP.
Methods: The study characterised Si-containing a-TCP blocks
designed for graft application and examined their osseintegration in rabbit tibiae using histological, histomorphometric and
micro-CT techniques. The block grafts were inserted into the
critical size defects of 15 rabbits, using both tibiae, and examined at 15, 30 and 60 days.
Results: Results showed that new bone grew in direct contact
with the block grafts and that the presence of silicon
improved the stability and osseointegration of the material.
Silicon doped TCP grafts showed enhanced mesenchymal cell
differentiation and increased osteoblast activity compared
with a-TCP. Furthermore, blocks with the highest concentration of silicon (3% C2S, 97% TCP) showed better dimensional
stability and increased bone-to-implant contact values after
60 days (67.6 5% lateral bone contact and 57.3 3% base
bone contact). None of the implanted materials were seen to
produce any adverse inflammation.
Conclusions and clinical implications: a-TCP ceramic blocks
containing 3% C2S, offer good bioactivity, biocompatibility
and allow new bone growth around the block and within the
graft body, making this an ideal block graft material. a-TCPss
stabilized in cylinder form allows the precise evaluation of
resorption, dimensional stability and its replacement by new
bone. The incorporation of silicon improves the materials
integration and compatibility, accelerates bone replacement
and enhances the properties of pure a-TCP, which is otherwise
resorbed too quickly and is less stable.

Engineering
Comparison of bone substitute biomaterials in

sinus lift surgery
Mara Piedad Ramrez-fernandez,1 Rafael Arcesio
Delgado-ruz,1 Jose Luis Calvo-guirado,1 Jose Eduardo
Mate-sanchezDe Val,1 Bruno Negri,1 Laura Lopezmar,1 Cristina Calabria-zapata,1 Guillermo Pardozamora,1 Gerardo Gomez-moreno,2 Javier Guardia2
1
Murcia University, Murcia, Spain, 2Granada University,
Granada, Spain
Background: A detailed in situ study and precise visualization
of the interface between the implant surface and newly

formed bone are necessary in order to make an effective
assessment of the bone integration process. Scanning Electron
Microscopy with Backscattered Electron Imaging (SEM-BSE)
technique sufficient resolution to allow exploration of the different biological processes of tissue healing involved in the
bone integration process that occurs at this interface.
Aim: The aim of this study was to carry outanultrastructural
study of the implant-to-bone interface and mineral degradationof two xenografts of animal origin, one porcine (OsteoBiolmp3), the other bovine (Endobon), in retrieved bone
biopsies following maxillary sinus augmentation, in 15 clinical cases.

Methods: Nine months after sinus lifting, bone cores were
harvested from the maxillary sinus. The specimens were processed for observation under a scanning electron microscope
with backscattered electron imaging (SEM-BSE). In addition,
chemical analysis and elemental mapping of the mineral compositionwere generated using a microanalytical system based
on energy-dispersive X-ray spectrometry (EDX).
Results: No clinical complications were evident during surgery. Scanning electron microscopy revealed that newly
formed bone had become closely attached to both xenografts.
Elemental analysis showed a significantly high Ca/P ratio in
the biomaterials and at the bone interface compared to bone
which suggests that there may be a gradual diffusion on Ca
ions from the biomaterials into the newly forming bone at the
interface as part of the biomaterials resorption process. EDX
analysis of the residual biomaterials at the different points
analyzed showed some particle categories with different mean
ratios of Ca/P according to size, pointing to different stages of
the resorption process. Histomorphometric measurements on
the bone biopsies showed that for the porcine xenograft, the
newly formed bone represented (23.5 2.4%), residual graft
material (25.1 2.3%) and for connective tissue (51.4 3.4%),
while for the bovine xenograft newly formed bone represented
(28.5 2.4%), residual graft material (31.3 2.3%) and nonmineralized connective tissue (40.2 3.4%).
Conclusions and clinical implications: The biomaterials assessed
in the study were shown to be biocompatible and osteoconductivewhen used asa bone substitutes for maxillary sinus elevation. The rate of residual graft material observed in this study,
confirmed substantial resorption of the grafted materials. Endobon is not complety resorbable material over the time period
covered by this study. Collagenized porcine xenografts proved
more resorbable than bovine xenografts. Both can be used as
possible bone substitutes without interfering with normal
reparative bone processes.

Engineering
Biomodel for calculating bone volumes to

planning bone regeneration surgery
Jose Luis Calvo-guirado,1 Jose Eduardo MatesanchezDe Val,1 Mara Piedad Ramrez-fernandez,1
Rafael Arcesio Delgado-ruz,1 Bruno Negri,1 Laura
Lopez-mar,1 Guillermo Pardo-zamora,1 Cristina
Calabria-zapata,1 Javier Guardia,2 Gerardo Gomezmoreno2
1
Granada, Spain
Background: Determining the volume of bone deficit for pur-
poses of oral and maxillofacial surgery is an important area for

research. Prior knowledge of bone quantity, volume and position can facilitate surgical procedures. Molding in layers
245
brings a series of advantages compared to traditional stereolithography, which is based on a subtraction model to obtain an
object, whilst composite powder molding builds in layers and
then refines them, achieving greater precision.
Aim: The aim of our study was to obtain, from helical CAT
scans, volumetric biomodels of bone for precisely determining
the biomaterial required for bone regeneration procedure, this
in order to validate the use of biomodels for calculating bone
volumes prior to planning bone regeneration surgery.
Methods: A casecontrol comparison with a total sample size
of 20 cases, 10 control and 10 test samples. Biomodels were
generated from helical CAT scans with 0.5 mm slices, without 3D reconstruction or image filters. Bone defects in premolar and molar areas were treated with titanium mesh and
xenograft (MP3) combined with resorbable carriers. Time
taken to carry out procedures with and without the use of biomodels (in minutes), discrepancies between the grafts performed with and without biomodels and bone defects (mm),
and postoperative complications were registered.
Results: No significant differences were recorded for measurements of width and length of bone defect between patient
bone and the biological models.
Conclusions and clinical implications: The use of biomodels
obtained by rapid prototyping is effective in treatment planning. Biomodels generated by rapid prototype composite molding is an effective tool for planning and a valid and reliable
resource for surgery. The precision of bioreplicas make it possible to obtain a graft from a donor site accurately and, by
doing so, reduce the time taken to carry out surgical procedures and also reduce morbidity.
graphic thermal imaging, EDX and element mapping analysis

were performed at 15, 30 and 60 days after graft insertion.
Results: Histomorphometric analysis at 30 days showed more
new bone formation in defects filled with Ossceram
4.41 0.23 mm than the test group 1.94 0.28 mm (P < 0.05).
Element analysis revealed higher percentages of Ca
(42.33 2.8%) and P (1.3 0.8%) in the test group than in the
control group (P < 0.05). Element mapping showed that Ca and
P were concentrated in medullar and cortical zones in the test
group but were concentrated only in cortical zones in the control group. Test group histomorphometry at 60 days showed
complete closure of the cortical defect 5.37 0.32 mm more
than the control group 2.3 0.54 mm. There was no cortical
defect closure or medullar bone formation in the control group
(P < 0.05). Element analysis revealed higher percentages of Ca
(32.26 21.7%) and P (1.5 0.3%) in the test group than in the
control group (P < 0.05).
Conclusions and clinical implications: Ossceram is biocompatible, partially resorbable and osteoconductive. Biphasic graftmaterial favors bone neoformation. The release of Ca and P
ions promoted new bone growth with trabecular formation
within the medullar area; it is possible that high levels of Ca
and P stimulate osteogenesis due to their effects on osteoblast
gene expression. After implantation B-TCP undergoes remodeling and is eventually completely replaced by new bone.

Engineering
Laura Lopez-mar,1 Mara Piedad Ramrez-fernandez,1

Jose Luis Calvo-guirado,1 Jose Eduardo MatesanchezDe Val,1 Rafael Arcesio Delgado-ruz,1 Bruno
Negri,1 Cristina Calabria-zapata,1 Guillermo Pardozamora,1 Javier Guardia,2 Gerardo Gomez-moreno2
Histomorphometric, EDX and element mapping

analysis of a B-tricalcium phosphate
Rafael Arcesio Delgado-ruz,1 Mara Piedad Ramrezfernandez,1 Jose Luis Calvo-guirado,1 Jose Eduardo
Mate-sanchezDe Val,1 Laura Lopez-mar,1 Bruno
Negri,1 Cristina Calabria-zapata,1 Guillermo Pardozamora,1 Javier Guardia,2 Gerardo Gomez-moreno2
1
Granada, Spain
Background: Few studies have included EDX analysis as a tool
for understanding the degradation process of a biomaterial.

Aim: The aim of the present study was to examine the in vivo
degradation process of new highly porous (95%) biphasic calcium phosphate (hydroxyapatite 60%/B-tricalcium phosphate
40%), used to fill critical size defects in rabbit tibiae, supplementing histomorphometric findings with radiographic
thermal imaging, EDX analysis and Ca/P ratio mapping at
different time stages.
Methods: Two critical size defects of 6 mm diameter were
created in both tibiae of 21 New Zealand rabbits, test group
(Ossceram) and control group. Histomorphometric, radio-
246

Engineering
Comparison of two materials for the

conservation of the bone
Granada, Spain
Background: Dental extraction results in reduction of the vol-
ume of bone tissue and gingival tissue in all its dimensions.

To prevent this, techniques such as atraumatic extraction, primary closure of soft tissue, gingival grafts or bone preservation
using bone substitutes and collagen membranes have been
used. The Oss Ceram Nano is a biphasic material composed
of 60% hydroxyapatite and 40% B-TCP. Its composition, high
porosity, interconnected pores and nano-surface properties
confer a great ability to be used as a substitute for bone tissue.
As a complement we have the Alveoprotect, a collagen threedimensional structure of a suitable size for cell growth and to
allow vascularization. It can be used to fill a post extraction
socket, cover a defect, as a carrier of substances or to protect
the membrane of the maxillary sinus and like haemosthatic.
Aim: Investigate the combination of Oss Ceram plus Alveoprotect in the preservation of bone defects in a Rabbit model.
Methods: Evaluate the Ossceram Nano and Alveoprotect in

stimulating new bone formation by histomorphometrical and
radiographic techniques in the tibiae of rabbits. A prospective
study at 2 months.
Results: Alveoprotect internal reabsorbs as quicker than external placement. As a membrane avoid soft tissue migration and
let the bone heals. Alveoprotect was reabsorbed after 30 days.
Ossceram is radioopaque, have a good radioopacity and can be
controlled by radiographic techniques, inside the deffect supports the bone formation as an scaffold. Used with Alveoprotect coating increase bone formation and bone remodelling.
Ossceram is partially reabsorbed after 60 days. The remanent
Ossceram continuing bringing a volume stability at the grafted
area.
Conclusions and clinical implications: Oss Ceram Nano is partially reabsorbable, preserves bone and used with alveoprotect
membrane increase bone formation levels in rabbit tibiae
defects. alveoprotect prevent soft tissue migration acting like
a barrier and is completely reabsorbable. There are no published works on the combination of Oss Ceram plus Alveoprotect in the preservation of bone defects in a Rabbit model.
Results: Four microvascular bone grafts failed during the heal-
ing period and had to be removed. The remaining grafts provided sufficient bone and a correct orientation to retain dental
implants. While iliac crest grafts provide adequate bone volume in vertical and horizontal dimension, primary stability in
fibula and scapula grafts is higher, however, bone volume is
reduced. This results in an unfavourable implant-to-crown
ratio making sufficient prosthetic rehabilitations, especially in
partial edentulous patients, difficult. Due to the even lower
vertical and horizontal dimension of the scapular graft,
implant retained rehabilitation are difficult with this graft.
Conclusions and clinical implications: Microvascular bone
grafts can help to functionally rehabilitate patients after resective surgery. All grafts can provide sufficient primary stability.

Engineering
Usefulness of a computer navigation system in

maxillary sinus augmentation
Kyoichiro Muranishi,1 Tomoo Takeda1
1

Engineering
Microvascular bone reconstruction and dental

implants after resective tumour surgery
Christian Mertens, Robin Seeberger, Michael Engel,
Jurgen Hoffmann, Kolja Freier
Department of Oral and Maxillofacial Surgery, University
Hospital Heidelberg, Heidelberg, Germany
Background: Free microvascular bone grafts from the iliac
crest, the fibula and the scapula are most commonly used to
reconstruct maxillary and mandibular bone defects after resective tumor surgery to successfully rehabilitate patients. Functional and aesthetic aspects have to be considered during bone
positioning to achieve sufficient facial support, but the bone
graft should also deliver sufficient bone in a correct threedimensional position to allow for a subsequent dental rehabilitation as well.
Aim: The aim of this study was to evaluate microvascular
bone grafts under the aspect of supplying adequate bone to
successfully retain dental implants and permitting a later prosthetic rehabilitation. Additionally the outcome of dental
implants placed in free microvascular bone grafts was analysed.
Methods: Sixty-two microvascular bone reconstructions were
performed after resective tumour surgery between September
2010 and February 2012 in the department of oral and maxillofacial surgery of the Heidelberg University. Thirty-five microvascular iliac crest grafts, 24 fibula grafts and three scapular
grafts were performed. The microvascular bone grafts were
checked for suitability to retain dental implants by using postoperative computed tomography and orthopanographs. Bone
dimension and bone orientation were analysed.
Department of Dentistry and Oral Maxillofacial Surgery, Hokuto
Hospital, Obihiro, Japan

Background: Computer navigation system is used in neurosur-
gery, orthopedics, otorhinolaryngology, and oral surgery to

monitor surgical sites in real time and allow minimally invasive, safe and reliable surgery. While studies on maxillary
cysts and maxillary cancer using this system have been
reported, few have described use of this system in maxillary
sinus augmentation.
Aim: Positioning of the lateral window and sinus lift procedure thus tend to be influenced by the experience of the operator. This report offers an overview of clinical investigations
into the usefulness of a computer navigation system in maxillary sinus augmentation.
Methods: Maxillary sinus floor augmentation for subsequent
implant therapy was conducted on two cases. The Stryker cart
system was used. Three processes are necessary for navigation:
imaging; image transfer; and registration. First, a reference
marker was attached to the skin surface on the head and computed tomography was performed. Next, the data were transferred to a workstation. The data were then registered. The
head was fixed in place, and infrared light-emitting diodes
(LEDS) were fixed. Marker positions were matched using
pointers, and consistency of positional relationships between
images on the navigation system and the patient was checked.
During the procedure, the sensor array camera detected the
site, and the site indicated by the pointer was continuously
displayed on transverse, frontal, sagittal and three-dimensional
images.
Results: Computer navigation system was used in two cases
of lateral window technique under general anesthesia, For
graft material, autologous bone taken from the mental or
ramus region was mixed with b-tricalcium phosphate (TCP)
and plateret-rich plasma (PRP). Six months after the proce-
247
dure, Straumann SLA implants were placed, and the superstructure was seated 4 months later. Progress remains favorable.
Conclusions and clinical implications: Navigation enables easy
monitoring of the lateral window technique via images. The
lateral window could be opened precisely at the most anterior
part of the maxillary sinus using the navigation system. In
addition, only a small access hole, almost the same size as the
head of the surgical instruments. Since new bone usually generated from host bone into cavity, leaving as large space of
host bone as possible, effectively induced bone generation.
Consequently this system is considered useful for performing
minimally invasive surgery.

Engineering
1,2

Engineering
Osteogenic and vascular potential of augmented

and non-augmented extraction sockets
Susanne Nahles,1 Claudia Nack,1 Kerrin Gratecap,1
Hermann Lage,1 John J. Nelson,2 Andres Stricker,3
Katja Nelson3
Department for CMF-Surgery, Charite, Campus Virchow, Berlin,
Germany, 2University South Alabama, AL, USA, 3Albert-Ludwig
Nidal Murra, Nikoline Parbo, Jytte Buhl, Kristian

Andersen,1,2 Sven Erik Nrholt1,2
1
Aarhus University Hospital, Aarhus, Denmark, 2Aarhus
University, Aarhus, Denmark

Background: Since 1979 fibula grafts have been used for
reconstruction of the mandible after mandibular segmental

resection to recreate form, function and aesthetic of the mandible. Anatomical proportions of the fibula graft enable
implant insertion and implant-supported, prosthetic rehabilitation.
Aim: To assess the survival rates and success rates of fibula
grafts, implants and implant-supported, prosthetic rehabilitation used for mandibular reconstruction in patients treated in
the years 19982011 at the Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Denmark.
Methods: Patient inclusion criteria were segmental mandibular resection and reconstruction with a fibula graft in the period 19982011. Patients with insufficient medical records
were excluded. Parameters were registered according to the
preoperative treatment course (sex, age, diagnosis, preoperative
radiation therapy), the peroperative treatment (resection, type
of graft, length of graft, osteotomies performed, osteosynthesis
used), and the postoperative treatment course (postsurgical
radiation, hyperbaric oxygen treatment, complications, number and type of implants, healing period, prosthetic rehabilitation, implants lost). Descriptive statistics were undertaken in
a spread sheet, Excel (Microsoft, USA).
Results: The survival rate of the fibula grafts was 97.3%, as
one of 37 fibula grafts was lost due to infection. Implant survival rate was 95.5%, as three of 67 implants were lost due to
infection. At the last follow-up visit, 83.6% of the implants
were in function. All implant-supported prosthetic rehabilitations were in function at the last follow-up, and in 85.7% no
prosthetic complications occurred. In general, a low rate of
complications occurred.
248
tion with fibula grafts is a reliable treatment modality with

few complications and high survival rate. Dental implants and
prosthetic rehabilitation had high survival rates and success
rates.
Mandibular reconstruction with fibula grafts and

implant-supported, prosthetic rehabilitation
1,2
Conclusions and clinical implications: Mandibular reconstruc-
University, Freiburg, Germany

Background: Healing processes in alveolar bone respectively in
extraction sockets has been recently studied in different investigations Scarce data are available about the role and sequence
of vascularization during the alveolar bone healing and about
the interactions between angiogenesis and osteogenesis of the
provisional matrix in socket healing.
Aim: The aim of the present immunohistological investigation was to define and compare the osteogenic potential to the
vascularization of the provisional matrix in grafted and
ungrafted extraction sockets after 4 and 12 weeks of healing.
Methods: A total of 33 Patients with 65 extraction sites participated in this study. After tooth extraction the sockets were
augmented with Bio-Oss collagen or non-augmented. At
implant placement after 4 or 12 weeks bone biopsies were
obtained. Within the specimens the osteogenic and endothelial potential of mesenchymal cells was analyzed in the provisional matrix using immunohistochemical analysis with three
monoclonal antibodies Cbfa1/Runx2, Osteocalcin (OC), and
CD31. Statistical analysis was performed using Mann-Whitney
U-test, Spearmans rank-order correlation coefficient, and the
two-factorial analysis for repeated measurements.
Results: Of the 65 extraction sockets, 25 (13 non-augmented,
12 augmented) sites after 4 weeks healing time and 40 (19
non-augmented, 21 augmented) sites after 12 weeks healing
time were involved in the study. No signs of acute or chronic
inflammation were noted in any specimens. After 4 weeks, a
median amount of 56% (1085%) of Cbfa1 positive cells and a
median amount of cells expressing OC was 21% (542%) was
measured. A median CD31 score of 5 was observed. After
12 weeks, a median amount of 61% (1990%) positive cells
expressed by Cbfa1/Runx2 staining a median amount of OC
positive cells of 9% (217%) was measured. The results at
12 weeks revealed a median score of CD31 positive cells of 3.
Conclusions and clinical implications: The results have shown
show that with increasing age a decreasing endothelial potential was observed not after 4 weeks but after 12 weeks thus it
suggests that the angiogenesis is diminished in older patients
in the later phase of healing in extraction sockets. Osteoblas-
tic activity in the provisional matrix was highest after

4 weeks of healing period. The active zone of bone formation
is found in the apical region of the extraction socket during
the early healing phase, shifting to the coronal region after
12 weeks. A peak of osteoblast activity within the first weeks
is followed by a reduction of mature osteoblasts with osteoblasts remaining in an inactive stage. The vascularity changed
in likewise fashion to the maturation of osteoblasts within
the observation period.

Engineering
Results: There
was no statistically significant difference

between groups regarding the degree of resorption of the graft
(P = 0.983), total bone area (P = 0.191) and remnant particles
(P = 0.348) and the proportion of active osteoblasts (P = 0.867).
There was a statistically significant difference in the vitality
rate between the groups (P = 0.043). The success rate of
implants in both groups was 100%.
Conclusions and clinical implications: In this study, fresh frozen allograft bone presented as a viable substitute to autologous bone graft in Sinus Lift surgery. However, it is necessary
a longer period of follow up to evaluated the implants and tissue performances in function.
Clinical and histomorfometric assessment of

fresh frozen human bone in maxillary sinus
augmentation

Engineering
Tatiana Regina Ramos NantesDe Castilho,1,2 Pedro

Tortamano,1 Jose Carlos Silva Andrade Junior,1 Israel
Chilvarquer,1,2 Michel Eli Lipiec Ximenez,1 Maria
Teresa Seixas Alves2
A pilot study of preservation of extraction site

with an simplified method
University of Sao Paulo, Sao Paulo, Brazil, 2Federal University of

Sao Paulo, Sao Paulo, Brazil
Jie Li,1 Jianghai Ning2

1
Kanwa dental Clinic, Beijing, China, 2PLA General Hospital,
Beijing, China
Background: Traditional extraction site preservation need bone
Background: Bone augmentation procedures prior to implant
placement in partially or totally edentulous patients has

become a routine treatment, aiming adequate prosthetic rehabilitation. The sinus floor elevation a surgical technique
known as Sinus Lift enables the regeneration of the posterior
maxilla with predictable outcomes. There are some variations
on the technical approach and several kinds of grafts, which
can be employed in chips or blocks, being alloplastic, xenogenous, autogenous or allograft. The autogenous bone is still
considered the gold standard even though it has the disadvantage of increasing operative morbidity since it needs a surgical
approach to obtain it, which can be intra or extra-oral. The
fresh frozen bone allograft from Tissue Bank is widely used in
medicine and more recently in dentistry as an option for grafting. The lower morbidity and short operation time resulted in
more postoperative comfort and quick recovery of the patient.
The lack of prospective clinical studies using the fresh frozen
bone allograft in Sinus Lift stimulated this study.
Aim: The aim of this prospective study is to evaluated the
clinical and histomorphometric data of the newly formed bone
tissue from fresh frozen human allogeneic bone graft in Sinus
Lift.
Methods: A total of 33 Sinus Lift were performed in 20
patients divided into control group (n = 8) who received autogenous bone from ramus and the experimental group (n = 12)
who received fresh frozen bone allograft in chips. After
6 months, 52 implants were installed and 50 biopsies were
collected for histomorphometric analysis. Computerized
tomography (CT) scans were performed on preoperative,
immediate and delayed postoperative to assess the degree of
resorption of the graft for each group (Multiple linear regression analysis and Students t-test).
graft to fill the socket and membrane or soft tissue graft to

cover the socket. Although this method was effective in
clinic, it is still time consuming and espensive. An simplified
method with calcium sulfate as graft which can be replace by
new bone at 812 weeks interval and absorbable gelatin
spongy as barrier which can be cloted with blood was developed and evaluated.
Aim: The aim of this study was to explore the simplified
method of extraction site preservation with tablet calcium sulfate and absorbable gelatin sponge.
Methods: Ten residual crown or roots were extracted with
minimal trauma. Granulated tissue was thoroughly removed.
Then tablet calcium sulfate (Ossteoset) was grafted to the
extraction socket. Absorbable gelatin spongewas applied to the
surface of graft material, and then the gingiva was sutured.
The tablet calcium sulfate can be minced to adjust to the size
of extraction socket. The extraction socket was allowed to
cure for 8 weeks. Then the implant was inserted and restored
as usual procedure.
Results: 10 patients with calcium sulfate as extraction site
preserve graft show satisfied results in the followed implant
procedure. It is much more simple and economic than the traditional GBR methods and the graft materials can be absorbed
simultaneously as the new bone formation. The absorbable
gelatin sponge can be replaced by healthy gingiva tissue.
Conclusions and clinical implications: Extraction site preservation with tablet sulfate and absorbable gelatin spongy was an
effective and economicalmethod instead of traditional GBR.
249

Engineering

Engineering
Treatment of sinus bone wall discontinuity

associated with alveolar vertical defect: a surgical
approach
Guided bone regeneration using a polyethylene

glycol hydrogel membrane
LucaDe Stavola, Davide Corrado Oberholtzer, Andrea

Gelio, Eriberto Bressan
Private Practice, Saint Maur, France
University of Padova, Padova, Italy
Background: The aim of using guided bone regeneration (GBR)
Background: When implant treatment and sinus lift procedure
fail, the anatomy of the posterior maxilla may often result in

a class V (Cawood & Hawell) and in a partial lateral and/or
crestal bone wall discontinuity accompanied with a fusion
between the oral and the maxillary mucosa. A traditional crestal incision may be impossible and the combination of vertical
augmentation with sinus lift procedures is associated with a
high risk of flap dehiscence.
Aim: To propose a safe surgical approach characterised by a
combination of an horizontal tunnel and a mandibular-boneblock graft to treat both the vertical and the sinus defects.
Methods: Five patients were treated. Bone was harvested from
the retromolar area and managed as proposed by Khoury
(bisected into two thin laminae). The flap design was characterised by a 10 mm-horizontal incision 3 mm above the
mucogengival junction and mesial to the bone-discontinuitydefect. A tunnel was elevated cranially as well as coronally,
the area of mucosa fusion was isolated and the tissue surgically bisected. The sinus was elevated through the existing
bone wall defect. One bone lamina was screwed coronally
defining the new vertical-crestal bone level. The area defined
by the cortical lamina was filled with particulated autogenous
bone, while the sinus was lifted with deproteinized bovine
bone mineral. The second lamina was screwed over the particulated bone and used for rebuilding the lateral wall of the
alveolar crest. Sutures were applied on the single horizontal
incision. The entire vertical graft was covered by intact
mucosa. After a 4-month-healing time, implants were inserted
in clinically well regenerated bone. Three months later,
implants were loaded.
Results: No complications such as dehiscences were recorded
after the bone graft procedures. Vertical bone resorption was
minimal and all implants were inserted as planned. By now
all implants are loaded and in function.
Conclusions and clinical implications: Treatment of vertical
bone defects is a high risk procedure and results more complex when associated to an abnormal anatomy involving the
sinus compartment. The surgical approach proposed is characterised by a lack of incisions involving the vertical graft, thus
minimising the chance of complications. The horizontal tunnel allows for the treatment of both the sinus and vertical
defects at the same time, avoiding an incision in the bone-discontinuity area.
250
Laurent Ohayon
membranes is to encourage proliferation of bone tissue cells

by excluding soft tissue cells, thus impeding the cellular competition described by Melcher in 1976. The various cell barriers offered to date, whether absorbable or non-absorbable, take
the form of fine, flexible or semi-rigid membranes. They are
available in prefabricated sizes and shapes, and therefore need
to be cut and adapted to the bone defect. Placing a bone filler
material between the membrane and the bone tissue allows
the addition of other osteoconductive, osteoinductive or osteogenic biological properties to the biomaterial while ensuring
maintenance of the space underneath the membrane during
the bone healing phase.
Aim: The aim of this presentation is to describe the usage of
a new, synthetic polyethylene glycol (PEG) membrane in different guided bone regeneration clinical cases.
Methods: The PEG hydrogel was conditioned in the form of
two double syringes. The contents of the syringes were mixed
by fully expelling the content of one syringe into the other so
that the two PEG components were diluted in their respective
buffers. The hydrogel membrane is then applied in a thin even
layer, from the periphery to the center of the bone defect surpassing by 12 mm on either side of the bone tissue to ensure
a complete hermetic seal between the biomaterial and soft tissue necessary for bone regeneration. Four different clinical
cases will using polyethylene glycol hydrogel membrane procedures over bone substitute will be presented like filling of
extraction sockets, peri-implant defects surgical treatment,
sinus lift and bone block techniques with titanium mesh for
enlargement of alveolar ridge.
Results: Clinical results for different GBR indications after
18 months show successful bone regeneration and thus confirm the role of the membrane in the different clinical situations.
Conclusions and clinical implications: The advantage of using
PEG hydrogel technology instead of conventional membranes
is that it simplifies surgery by means of its liquid application
affecting a fine, even layer when applied to the bone substitute. This hydrogel layer solidifies after 90 s, isolating the
bone filler biomaterial from the soft tissues, thus enabling
good progress of the guided bone regeneration. The study of
this new PEG hydrogel membrane in large samples will enable
the value of its use for guided bone regeneration in different
clinical situations to be analyzed.

Engineering

Engineering
Vertical bone augmentation using collagen

membrane, rhPDGF-BB and implant-fixed
deproteinized bovine bone blocks
Clinical evaluation of fresh-frozen bone in

horizontal augmentation maxilla
Victor Palarie, Eik Schiegnitz, Viorel Nacu, Florian

Draenert,2 Valentin Topalo,1 Bilal Al Nawas,2 Peer
Kammerer2
1
State University of Medicine and Pharmacy, Chisinau, Moldova,
Eugenio Miguel Pereira,1 Cesar Augusto Thome,2

Thomaz Wassal,2 Alexander Dalvia Salvoni,2
Fernando Alberto Guerra1
1
Universidade de Coimbra, Coimbra, Portugal, 2Faculdade e

Centro de Pesquisas Odontologicas, Sao Leopoldo Mandic,
Campinas, Brazil
Background: Combinations of bone substitute block materials
Background: The use of allografts in maxillofacial reconstruc-
with membrane techniques as well as with growth factors are

possible options to enhance the prognosis of vertical bone augmentation. However, very little evidence exists regarding the
influence of the deproteineized bovine bone (DBB) recombinant human platelet-derived growth factor-BB (rhPDGF-BB)
complex and deproteineized bovine bone alone in combination
with resorbable membranes in early healing of vertical bone
defects. Also, the question of possible advantages by stabile
fixation ofalloplastic block-materials in combination with
growth factors and membrane techniques has not been
answered.
Aim: The aim of the study was to compare the influence of a
collagen membrane and a signal protein (rhPDGF-BB) on vertical bone augmentation with a stable fixed block material
(DBB).
Methods: In 12 rabbit, a DBB-block was implant-fixed on the
tibia in a split-leg-design. Included were: DBB only (control),
DBB + collagen membrane (test), DBB + rhPDGF-BB (test) and
DBB + rhPDGF-BB + collagen membrane (test). Twenty-four
samples were examined after 3 (n = 12) and 6 weeks (n = 12).
Calculated parameters were new bone area (NBA;%) and new
vertical bone height (VBH; mm).
Results: After 3 weeks, total mean NBA as well as VBH-values in the different groups did not differ significantly. Though,
there was a trend towards higher NBA values in the rhPDGFBB-group without membrane (NBA group 1a: 20 9; 1b:
16.3 8.9, 2a: 35.28 3.8, 2b: 15.4 15.4; VBH group 1a:
1.1 0.11, 1b: 0.9 0.17, 2a: 0.9 0.15, 2b: 0.7 0.61). After
6 weeks, both membrane-groups showed a significant higher
NBA and VBH independent to the use of rhPDGF-BB (all:
P < 0.01; NBA group 3a: 2.5 2.5, 3b: 28.5 7.8, 4a: 5.3 1.9,
4b: 35.5 4.8; VBH group 3a: 0.4 0.14, 3b: 2 0.4, 4a:
0.62 0.21, 4b: 1.9 0.14).
Conclusions and clinical implications: For vertical augmentation, the addition of rhPDGF-BB to DBB-blocks may increase
early bone growth. In the later phase, the use of a collagen
membrane enhances new bone volume and height to a statistically significant greater extend. Even if the results are significant higher than in the non-membrane groups, the low gain
of bone after the short time periods still needs improvement.
tion procedures is well known in dentistry. However, corticocancellous allograft bone blocks from iliac crest, are not
considered the first choice, because they are stigmatized by
some unpredictable behavior. Nonetheless, severe atrophy of
the edentulous maxilla requiring bone augmentation as a prerequisite for further successful implant placement has converted the use of allogenic bone graft materials into an
important alternative that overcomes limitations in available
self-donor sites and the need for added surgical procedures.
Aim: This study evaluated the dimensional changes of iliac
crest allografts adapted over the vestibular surface of the edentulous maxilla.
Methods: Eleven consecutive patients with 43 corticocancellous fresh-frozen bone blocks from a Musculoskeletal Tissue
Bank, 32 of these from the anterior area (group I) and 11 from
the posterior area (group II) were included in this study fulfilling the following inclusion criteria: requirement of bone augmentation in the maxilla, minimum of 10 mm height in
residual alveolar ridge; absence of debilitating systemic diseases; treatment protocol acceptance. The allografts were
thawed for 30 min prior to surgery, and then the blocks were
sculpted with rotary instruments. At surgery, the residual
crests were measured and a perfect adaptation and fixation of
bone blocks was pursued allowing further measurements.
After a 6-months healing period, a two-stage approach was
performed and a third measurement was obtained before
implants placement into the grafted ridge. Analysis of variance
was used to evaluate changes.
Results: The statistical analysis of the different measurements
between the first and the second surgery stage showed an horizontal bone augmentation mean of 4.61 mm and 4.4 mm for
groups l and ll, respectively. Considering bone resorption the
results were 12.14% and 13.00%, respectively.
Conclusions and clinical implications: Corticocancellous freshfrozen bone blocks from iliac crest can be considered a suitable and predictable alternative to autogenous grafts in the
reconstruction of atrophic maxilla.
University Medical Center, Mainz, Germany
251

Engineering

Engineering
In vivo evaluation of synthetic porous calcium

phosphates
A comparison of spontaneous healing vs. ridge

preservation with secondary soft tissue healing
Marzio Piccinini,1 Eleonora Preve,1 Alberto Rebaudi2,3
Antonio Barone, Massimiliano Ricci, Ugo Covani
University of Pisa, Pisa, Italy
Eurocoating SpA R&D Department, Pergine Valsugana Trento,
Italy, 2CLID Department, University of Genova, Genova, Italy,

3
Biomaterials Clinical Research Association BIOCRA, Genova, Italy
Background: Clinical success has been obtained by grafting the
maxillary sinus with different synthetic materials. New bone

formation after sinus graft procedure was demonstrated
through histologic analysis in animals and in humans. Calcium phosphates (CaP) as hydroxyapatite (HA), beta-tricalcium
phosphate (bTCP) and their combinations (HA/bTCP) have
been already applied as synthetic bone grafts, but an innovative composite material HA/TTCP with higher mechanical
strength was also proposed in this work. Granules spherical
morphology allows easy injectability into bone voids; intragranules macroporosity is fundamental for tissue and vascular
ingrowth thus determining fast implants osteointegration.
Aim: The aim of this study is the in vivo evaluation of bone
ingrowth potential, the osteointegration level and bioresorption
behavior of different synthetic calcium phosphate granules.
Methods: CaP bone grafts were supplied by Eurocoating in
four composition (HA, bTCP, HA/bTCP, HA/TTCP) in spherical porous granules form (300600 lm). In vitro studies. The
solubility was evaluated in MES (pH 5.5) and TRIS (pH 7.3)
solutions. To confirm granules purity and absence of any toxic
effect, cytotoxicity tests were performed on a cell line of mice
fibroblasts Balb/c 3T3 according to EN ISO 10933-5. In vivo
studies. Bone implantation study was planned and designed in
agreement with ISO 10993-6. Granules were implanted in
femurs of New Zealand white rabbit and explantation times
were 6, 26 and 52 weeks. A histological study was performed
and lCT images were also acquired. In addition, sinus lift augmentation was performed on two adult primates (Macaca Fascicularis) using HA/TTCP granules.
Results: Granules with biphasic compositions are dissolved
faster than monophasic ones. All the granules composition are
non cytotoxic as demonstrated by vitality assay on cells. Six
week after implantation in rabbit femur neither local toxicity
nor inflammations reactions were observed for all CaP granules. They were partially resorbed, fully integrated in the bone
tissue and surrounded by a large amount of neoformed bone,
as also lCT images showed. Twenty-six and 52 weeks data
are under collection. Good results have been also confirmed in
a primates model after 4 months of implantation.
Conclusions and clinical implications: Results suggest that the
porous granules proposed in the present work can be used as
bone-fillers material in the field of bone regeneration. These
features should facilitate bone tissue ingrowth and bone void
filling as shown by preliminary in vivo experiments. Biomaterials seem to well integrate in newly formed bone showing
good osteoconductive properties.
252
Background: As a consequence of extraction, the height of the
buccal wall tends to decrease and results in the disappearance of

bundle bone. In order to modify bone remodelling after extraction, various ridge preservation techniques have been proposed.
Aim: The present research was drawn up with the following
considerations in mind: to evaluate and to compare changes of
hard and soft tissues in post-extraction sockets which received
a ridge preservation procedure, with post-extraction sockets
which had healed naturally.
Methods: Each patient was randomly allocated to a test or
control group using a specific software package. After extraction the sockets were carefully inspected and any granulation
tissue was removed. The control sites received silk sutures to
stabilize the clot without any grafting material. The test sites
were grafted with corticocancellous porcine bone and a collagen membrane. All experimental sites had the membranes left
exposed to the oral cavity with a secondary wound healing.
The thickness of buccal alveolar bone, if present, was carefully
measured at the time of tooth extraction using a calliper at
1 mm from the edge of the wall. The following clinical parameters were evaluated at baseline and after 4 months at implant
placement: vertical bone changes, horizontal bone changes
and width of keratinized gingiva. The length, diameter and
need for additional bone augmentation were assessed for both
groups at the time of implant insertion.
Results: The control group showed vertical bone resorption of
1 0.7 mm, 2.1 0.6 mm, 1 0.8 mm and 2 0.73 mm at
mesial, vestibular, distal and lingual sites, respectively. Moreover, changes in horizontal dimension showed an average
resorption of 3.6 0.72 mm. The test sites showed a horizontal
bone
remodelling
of
0.3 0.76 mm,
1.1 0.96 mm,
0.3 0.85 mm, 0.9 0.98 mm at the mesial, vestibular, distal
and lingual sites, respectively. The horizontal bone resorption
at the test sites was 1.6 0.55 mm. The keratinized gingiva
showed a coronal shift of 0.7 mm in the control group when
compared to 1.1 mm in the test group. In addition, 42% of sites
in the control group required an additional bone augmentation
at implant placement, when compared to 7% in the test sites.
Conclusions and clinical implications: This study clearly
pointed out that an alveolar ridge preservation technique performed with collagenated porcine bone and a resorbable membrane according to the procedure reported in this study - was
able to limit the contour changes after tooth extraction.
Finally, the test sites showed a better preservation of facial
keratinized tissue when compared to control sites; grafted
sites allowed the placement of longer and wider implants
when compared to implants inserted in non-grafted sites.

Engineering

Engineering
Mandibular symphysis and ramus as cells source

for bone tissue engineering
Sinus Floor Elevation using the osteotome

technique without grafting material
Emanuela Ferraz, Samuel Xavier, Marcio Beloti,

Adalberto Rosa
Sermet Sahin,1 Mbulent Kurtis,2 Mesut Akyol,3

Mehmet Bozyel1
Faculty of Dentistry of Ribeirao Preto, University of Sao Paulo,
Ribeirao Preto, Brazil
Dentistry, Gazi University, Ankara, Turkey, 3Faculty of
Gulhane Military Medical Academy, Ankara, Turkey, 2Faculty of
Medicine, Yildirim Beyazit University, Ankara, Turkey

Background: Mandibular symphysis and ramus are common
intraoral harvesting sites of bone graft for alveolar reconstruction of atrophied alveolar ridges. While their clinical pros and
cons as bone grafts are well known, their potential as cell
source for bone tissue engineering procedures has not yet been
explored.
Aim: Thus, we aimed at comparing in vitro osteoblasts
derived from human mandibular symphysis and ramus by
evaluating cell growth (MTT assay), alkaline phosphatase
(Alp) activity (thymolphthalein releasing), mineralized matrix
formation (alizarin red staining), and gene expression (qPCR)
of the osteoblast markers: runt-related transcription factor 2
(Runx2), collagen type 1 (Col1), bone sialoprotein (Bsp), osteopontin (Op), and osteocalcin (Oc).
Methods: Osteoblasts from mandibular symphysis and ramus
fragments from the same patient (n = 3) were enzymatically
released, expanded, and cultured in osteogenic medium for up
to 17 days and all comparisons were donor-matched. Data
were analysed by ANOVA and MannWhitney tests.
Results: Cells derived from symphysis and ramus displayed
the same growth pattern increasing from day 3 to 7 and being
steady from day 7 to 10, without any difference related to cell
origin (P = 0.24). Alp activity assayed at days 7, 10 and 14 was
higher in cultures derived from symphysis (P = 0.0001) peaking at 10 days (P = 0.03) and mineralized matrix formation
evaluated at day 17 was the same in both cultures (P = 0.5).
qPCR was carried out at 10 days and showed that the expression of Runx2, Bsp, and Op was higher in osteoblasts derived
from ramus (P = 0.02 for all of them) while the expression of
Col1 and Oc was not affected by the cell source.
Conclusions and clinical implications: These results were not
related to either the patients, as the comparisons were donormatched, or the culture conditions that were kept rigorously
identical. Such findings reveal that cells from symphysis and
ramus despite sharing the same embryonic origin are different
in terms of phenotype and genotype expression. Apparently
these differences did not drive the cultures toward distinct
osteogenic potential as cells from symphysis and ramus exhibited similar mineralizing capacity. Based on this, it would be
worth to carry out further in vitro and in vivo investigations
to determine the best site as cell source to be used for bone
reconstruction based on tissue engineering principles. Financial support: FAPESP and CNPq.
Background: The technique which is known as the Summers
technique, may be considered to be more conservative and

less invasive than the lateral approach. A small osteotomy is
performed through the alveolar crest of the edentulous ridge at
the inferior border of the maxillary sinus.
Aim: The aim of this study was to evaluate the clinical outcome of implants placed in the posterior maxilla with the
osteotome sinus floor elevation technique without grafting.
Methods: During 2009 to 2011, 29 Straumann and MIS dental
implants were inserted in 19 patients. The surgical technique
was the original osteotome technique presented by Summers.
The median of residual bone height was 6.5 (Interquartile
Range: 2.0) (49 mm).
Results: The survival rate of 90.7% for implants placed in
transalveolary augmented sinuses, after a mean follow-up time
of 9.9 months in function. From 29 implants inserted, two
were lost before loading. The median of success rate was
100% (Interquartile Range: 1.0). The success rate was determined using the Albrektsson et al. criteria.
Conclusions and clinical implications: The osteotome technique
without bone grafts was found a reliable metod in the treatment
of 19 patients for implant insertion in the posterior maxilla.

Engineering
Treatment of severely resorbed alveolar ridges

with calvarial bone grafts
Dime Sapundziev, Natasa Ihan Hren, Vojislav
Didanovic, Andrej Kansky, Miha Kocar
University Medical Centre Ljubljana, Ljubljana, Slovenia
Background: Resorption of the alveolar ridge is process that
occurs after teeth loss. Its severity can seriously compromise

the successful outcome of implant treatment. Several methods
for augmentation with different types of bone grafts exist but
unfortunately none of them prevails.
Aim: The aim of our clinical study is to present our experience and success rate in treating severely resorbed alveolar
ridges with calvarial free bone grafts.
Methods: We have performed augmentation with calvarial free
bone grafts in five female patients age from 28 to 84 because
of severe alveolar ridge atrophy. In one patient the augmentation was performed on a vascularized fibula bone graft. Two
253
patients received a bone grafts in the maxilla and in the other

two patients in both jaws. In one patient 3D augmentation of
the alveolar ridge was performed. The graft elevation in three
patients was performed with surgical handpice using bone
chisels and in two patients with piezosurgery. All patients
received antibiotic and analgesic therapy post operatively. The
postoperative early and late complications were followed. The
bone gain was measured on panoramic X-ray immediately post
operation to evaluate the graft position and with CB-CT three
mounts before implant placement. Bone gain measured was
from 37 mm height and 69 mm of width. In four patients
additional bone particles and xenogenic bone grafts were used.
In three patients the grafts were covered with membrane.
Eighteen implants were inserted in the augmented areas. All
implants were covered with xenogenic bone grafts. The primary stability was achieved in all patients and was measured
with Osstell expressed with ISQ values. The implant placement and bone resorption were radiologically followed.
Results: In none of the patients we did not observed serious
complications during graft harvesting. In one patient we had
moderate bleeding from the dioploic vessels that was stopped
with local haemostatic measures. In two patients the durra
was exposed without neurological complications. We did not
observed total graft rejection. In two patients partial graft
exposure occurred and in one patient only screw exposure.
During the implant insertions no complications occurred, all
implants were primary stable. No implant exposure and bone
resorbtion occurred after loading.
Conclusions and clinical implications: Despite minor complications associated with the donor site augmentation of atrophic
jaws with calvarial bone grafts is predictable and reliable procedure. This is due to the membranous origin of the calvarial
bones and their compact structure.

Engineering
Ridge preservation using acellular dermal matrix

and bone substitute with P-15:
histomorphometric results in humans
Patricia Fernandes, Sergio ScombattiDe Souza,
Arthur Novaes Jr, Mario Taba Jr, Daniela Palioto,
Marcio Grisi, Valdir Muglia
School of Dentistry of Ribeirao Preto, University of Sao Paulo,
(ADM) and anorganic bovine bone matrix with synthetic cellbinding peptide P-15 (ABM/P-15) to preserve alveolar bone
after tooth extraction.
Methods: Eighteen patients in need of extraction of maxillary
anterior teeth were selected and randomly assigned to the Test
Group (ADM plus ABM/P-15) or the Control Group (ADM
only). Clinical measurements of external vertical palatal measurement (EVPM), external vertical buccal measurement
(EVBM), and alveolar horizontal measurement (AHM) were
recorded initially and at 6 months after ridge-preservation procedures. Bone biopsies were taken 6 months after ridge preservation procedures in ten patients, during the placement of
implants, and histomorphometric measurements of the
amount of newly formed bone area (NBA) and fibrous tissue
plus marrow spaces (FTMS) were analyzed.
Results: Clinical measurements showed no statistically significant differences between test and control groups initially and at
6 months, and intragroup analysis showed a statistically significant reduction in the measurements for both groups. Considering 06 month variations, the differences in EVPM and EVBM
were not statistically significant; however, there was a statistically significant difference in AHM (P < 0.05), showing less variation in test group. The histomorphometric analysis showed
38.66% of new bone tissue and 54.5% of fibrous tissue and marrow spaces in the control group. The experimental group presented 29.13% of new bone area, 42.4% of fibrous tissue plus
marrow space and 20.67% of residual graft particles. The NBA
and FTMS parameters showed higher values for the control
group, and these differences were statistically significant when
compared to the test group (P = 0.03).
Conclusions and clinical implications: It was concluded that:
ADM acted as a membrane; the group with ADM alone histomorphometrically presented more new bone formation after
6 months (probably because the bone substitute is still undergoing resorption process); and the association of ABM/P-15
with ADM resulted in better quantitative clinical results and
should be used, instead of ADM alone, for preservation of the
alveolar ridge after extraction of anterior maxillary teeth.

Engineering
A modified open barrier technique for guided

bone regeneration
Ribeirao Preto, Brazil
Kiyotaka Shibahara,1 Ryo Jimbo,2 Yoshinori

Tateyama,3 Izumi Asahina4
Background: Preventing the ridge collapse after the extraction
of maxillary anterior teeth is vital to an esthetic restorative

result. The general understanding is that bone graft placement
in the extraction socket should offset the catabolic processes
observed within the crestal ridge. Therefore, several procedures, such as the use of bone autografts, bone replacement
materials, and regenerative techniques, have been proposed to
prevent and correct alveolar bone resorption.
Aim: The aim of this study was to analyze by clinical and histomorphometric parameters the use of acellular dermal matrix
Faculty of Odontology, Malmo University, Malmo, Sweden,
254
Private Practice, Dazaifu, Japan, 2Department of Prosthodontics,
Private Practice, Kurume, Japan, 4Division of Regenerative Oral
Surgery, Nagasaki University, Nagasaki, Japan

Background: Guided Bone Regeneration (GBR) with d-PTFE
membrane is known as the Open Barrier Regeneration Technique, or the Open Barrier Membrane Technique (OBMT).
Due its high density and small porosity size, the possibility
for bacterial contamination is limited.
Aim: To utilize these membrane for various GBR applica-
tions, and classified them for the post-evaluation of bone augmentation.

Methods: CytoplastTM membranes, GBR-200, TXT-200, Ti250 (OSTEOGENICS, USA) were utilized for this technique.
We selected 74 cases (36 male and 38 female) operated by the
same oral surgeon from October 1, 2009 to September 31, 2011
using d-PTFE membrane. All cases were classified with the following parameters, simultaneous/delayed implant placement, with/without primary closure, and with/without
membrane fixation by screws. Pre-operative CT-scan and panoramic X-ray was compared to post-operation. Surgical complication, amount of augmented bone, and bone resorption were
evaluated by X-ray, and by clinical examination. The degree of
membrane exposure was classified into three types: within 1/3,
within 1/2, and over 1/2 size of the GBR membrane.
Results: All cases examined presented exposure of the d-PTFE
membrane. In one delayed case with primary closure, and
without screw membrane fixation, we experienced mandibular
nerve palsy, and no augmented bone. In another case in the
mandibular anterior region with the combination of Ti-Mesh
and d-PTFE membrane, there was little augmented bone.
Otherwise all other cases were successfully augmented, and
the implants were placed ideally. The time for placement of
the implants was on average, 4 months. The size of exposure
of the membrane was over 1/2 size of membrane in almost all
the cases.
Conclusions and clinical implications: Membrane contact to the
nerve may have caused the nerve palsy in one case, however
the symptoms relieved after the membrane removal. The original OBMT is a technique with no primary closure, and no
fixation of the membrane. We have modified this technique in
order to broaden the application range, for example for use on
teeth extracted sites. Needless to say, the complexity of the
technique was naturally dependent on the number, and the
volume of the alveolar wall. Since the OBMT is free of release
incision, and fixation of the membrane, it is an extremely useful method for bone augmentation. However, certain degree of
bone resorption was detected. On the other hand, there was
little resorption in the case of the membrane fixed group, and
it could be a novel technique to increase the reliability of bone
augmentation in complicated situations.

Engineering
Sinus bone formation after Schneiderian

membrane elevation and implant placement
Nicolas Strube
2007; Fermergard 2009; Cricchio 2011; Volpe 2011) have demonstrated that the elevation of the Schneiderian membrane
with simultaneous implants placement result in bone formation.
Aim: To evaluate the radiographic results of bone formation
around implants inserted in a void space created by the elevation of the sinus membrane without adding any bone grafting
material.
Methods: Twenty-eight patients with 2.59 mm of residual
alveolar bone were consecutively included from January 2009
to September 2011. Thirty-seven AstraTech dental implants
(913 mm) were placed in 28 sinus. Sixteen sinus elevations
was performed with a lateral approach technique and 12 using
an alveolar approach. The sinus mucosal lining was elevated
and implants were installed in the residual subantral bone
without adding any bone grafting material in the void space.
One or two stage procedures were used depending on primary
stability. CBCT or periapical radiographs (with angulator and
silicon re-positional key) were performed pre-surgically, immediately post surgically, 46 months post surgically and then
annually to evaluate bone formation below the sinus membrane and marginal bone loss.
Results: All implants were stable after 6 months of healing.
No implants were lost at this time. The Radiographic examination demonstrated new bone formation in 78.7% of the
cases after 6 months. The average bone gain in the sinus was
5.81 mm +/- 2.22 mm after a minimum of 6 months. No relationship was observed between bone formation height and the
length of implants not covered with bone at T0.
Conclusions and clinical implications: Sinus membrane elevation and immediate implant placement without the use of
additional bone grafting material was found to be a predictable
technique for bone augmentation of the maxillary sinus. We
assume that the formation of new bone was obtained according to the same mechanisms as the ones described in guided
bone regeneration. We believe that this technique reduces the
risks of morbidity associated with bone graft harvesting. Further histologic analysis are needed to confirm these findings.

Engineering
PRF vs. xenograft in sinus augmentation

procedures densitometric analysis
Mato Susic,1 Matija Gikic,2 Marko Granic,1 Irina
Filipovic Zore,1 Dragana Gabric Panduric1
1
Department of Oral Surgery, School of Dental medicine,
University of Zagreb, Zagreb, Croatia, 2Private Dental Practise,

Zagreb, Croatia
Nantes, France
Background: The autologous platelet concentrates PlateletBackground: Implant supported prosthetic restorations in the
severly atrophic posterior maxilla have been successfully performed for the last two decades with various sinus augmentation techniques. The use of grafting material is anticipated to
be necessary. However, recent studies (Lundgren 2004; Thor
Rich Plasma (PRP) and Platelet-Rich Fibrin (PRF) are used in

various medical fields, particularly in oral and maxillofacial
surgery. Platelet-rich fibrin (PRF) isderived from an autogenous preparation of concentrated plateletsthat containes high
levels of polypeptide growth factors and therefore has the
255
potential to be used as regenerative treatment for bone defects.

Growth factors are the key elements in wound healing, particularly in bone regeneration.
Aim: The purpose of this study was to examine the suitability
of autologous PRF in combination with xenograft as regenerative treatment for maxillary sinus augmentation in humans
and compare it to xenograft alone using densitometric measurements.
Methods: The sample of presented study consists of 10
patients partially edentoulous in the lateral region of the
upper jaw. Lateral approach for maxillary sinus augmentation
with immediate placement of two dental implants were used
in all of 10 patients. In the first group of five patients sinus
augmentation was performed using xenographic bone graft
(Bio-Oss, Geistlich, Germany) only and finally covered with
resorbable collagen membrane (Bio-Gide, Geistlich, Germany). In the second group of five patients sinus augmentation was performed using combination of autologous PRF and
xenograft (Bio-Oss, Geistlich, Germany) and covered using
combination of resorbable collagen membrane (Bio-Gide,
Geistlich, Germany) and PRF membrane. Following the healing period of 6 months, the osseointegration of inserted
implants was assessed with resonance frequency analysis and
considered adequate. All inserted implants were loaded with
metal-ceramic restorations. All patients were followed for
18 months after loading through clinical follow-ups and digital
radiographic imaging after 6, 12 and 18 months. Densitometric analysis was done based on radiographic images.
Results: After comparing the average densities of all inserted
implants, the results showed statistically significant increase
of density in group of patients where combination of xenograft
and autologous PRF for sinus augmentation was used.
Conclusions and clinical implications: The results of this study
indicate that PRF can improve densitometric parameters associated with maxillary sinus floor elevation procedures and
immediate implant placement, improving clinical implant stability and promoting bone healing following augmentation.
PRF can be used as an effective modality for promoting bone
healing and osseointegration precess.

Engineering
Treatment of oroantral fistula defect with

autogenous bone cylinder and implant
rehabilitation; a case report
Hakan Yusuf Tuncer,1 Nuray Er,2 C
igdem Karaca2
1
Private Practice, Ankara, Turkey, 2Hacettepe University,
Ankara, Turkey
Background: Oro-antral communications (OACs) commonly
ocur after extraction of the first and second molars. If the

communication fails to close spontaneously, it remains patent
and epithelialized so that an oro-antral fistula (OAF) develops.
There are numerous techniques in the literature for the treatment of oroantral fistula and most of them are focused on soft
256
tissue closure. With this approach the bone defect remains

and the implant placement to the region becomes impossible.
Aim: The aim of this study is to present the result of the
autogenous bone grafting of an oroantral fistula defect, sinus
floor elevation and dental implant placement.
Methods: A 43 year old female patient with an oroantral fistula defect was enrolled to the study. The grafting was performed with a trephine burr and chin graft stabilised to the
recipient area via press fit technique. Three months later the
sinus lift operation was performed. After additional three
month of healing the dental implant was placed.
Results: The implant was restored 2 months later and in function for 18 months without any complications. The donor site
healed without any sensorial complications.
Conclusions and clinical implications: The intraorally harvested
autogenous bone blocks are safe and easy alternatives in the
management of OAF closure and bone repair. This technique
allows the bone repair and implant rehabilitation of the
patients who experienced severe or mutilating dental procedures.

Engineering
Clinical and histological results of socket

preservation using Fortoss Vital
Cemal Ucer,1 David Charles Mangham,2 Les Coulton3
1
University of Salford, Manchester, United Kingdom, 2Robert
Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United

Kingdom, 3Academic Unit of Bone Biology, Department of
Human Metabolism, University of Sheffield Medical School,
Sheffield, United Kingdom
Background: Socket preservation has been established as an
effective treatment modality for maintaining ridge dimensions

in cases of planned implant placement. Current research is
active in identifying ideal socket filling materials for successful clinical outcome.
Aim: To report early findings from a pilot trial to evaluate a
synthetic resorbable bone graft (Fortoss VITAL, Biocomposites,
UK) as a suitable material in socket preservation, utilizing
clinical observations, histological analysis and micro-computer tomography (l-CT). Previous studies have determined
that this graft material develops a net negative surface charge
when placed in an aqueous medium such as the extra cellular
matrix in-vivo. It is claimed that this feature enhances protein
attachment and subsequent osteoblasts response.
Methods: Following atraumatic extraction, a series of five
patients underwent socket preservation using a synthetic bone
graft material presented as a powder and liquid. When combined, the components formed a setting paste which was
applied to the sockets prior to soft tissue closure. Immediately
before planned implant placement, a core biopsy (1.7 mm
diameter) was harvested from each augmented site at a mean
follow-up of 10 weeks post grafting (Range 812 weeks). The
biopsies underwent initial l-CT analysis to evaluate bone
regeneration and graft resorption followed by histological analysis to qualitatively access new bone formation, and evaluate
the host response to the implant material and remodelling.
Results: The synthetic bone graft material demonstrated a significant bone regenerative response within a short time frame.
Biopsies indicated almost complete resorbtion of the graft
material coupled with virtually complete replacement with
new viable bone. Integration of residual graft material into
new bone tissue was evident. No acute inflammation or lymphatic response from the host was observed in response to the
material. Successful subsequent implant placement was
achieved in each patient.
Conclusions and clinical implications: The results from the
pilot study indicate that the synthetic material has efficient
osteoregenerative capability with the regeneration of new viable bone almost complete within 12 weeks. These findings
indicate the material may offer clinical advantages for early
implant placement.

Engineering
Survival rate of microvascular transplants for

further implantation
Sascha Virnik, Alexander Gaggl, Daniel Jamnig,
Fm Chiari
Department of Oral and Maxillofacial Surgery, Klagenfurt,
Austria
Background: For the reconstruction in the MKG surgery the
microvascular transplants represent an important aspect to

social, working and aesthetic functions for patients after a
tumour or trauma. This study shows three microvascular
cases these have been the first time planned world wide with
the CMF system. This system allows you make a virtual surgery. With this planning will be the patient surgery virtually
on the computer program and through with drilling template
on the patient implemented.
Aim: (1) Will be shorter surgery time on the patient. (2) Fewer
donor site morbidity this will be reduced. (3) Perfect fit in the
maxillar/mandibular. (4) No secondary surgery will be
needed.5. it will be all-around better aesthetic outcome.
Methods: Three patients received a microvascular transplants
from pelvis (2), Fibula (1) and will be treated with implants.
All of them were compared and evaluated. We have no
implant loss.
Results: Microvascular transplants can be used successfully to
reconstruct the alveolar ridge. The transplant can be adjusted
individually in order to carry out an implant with a strong
supply. The big advantage of the surgery is. (1) Will be shorter
surgery time on the patient. (2) Fewer donor site morbidity
this will be reduced. (3) Perfect fit in the maxillar/mandibular.
(4) No secondary surgery will be needed. (5) It will be allaround better aesthetic outcome.
Conclusions and clinical implications: Microvascular transplants can be used successfully to reconstruct the alveolar
ridge. The transplant can be adjusted individually in order to

carry out an implant with a strong supply.

Engineering
Computer-aided reconstruction with distraction

osteogenesis for post-traumatic alveolar ridge
defects
Xudong Wang,1 Ling Li,2 Yiqun Wu,1 Hongchang Lai1
1
9th Peoples Hospital, Shanghai, China, 2Art Dentistry Clinic,

Shanghai, China
Background: Distraction osteogenesis (DO) is an established
method to gain bone. The post-traumatic alveolar deficiency is

common and difficult to be treated. The vector of the distractor is crucial for the direction of new bone formation and the
later on implantation.
Aim: The aim of this study is to find out the feasibility of
using the three dimensional computer software to help to
decide the vector of the distractor.
Methods: Reconstructions were done in eight patients (five
male, three female), average age was 26. The patients were
taken computerize tomographic scanning for the jaw bones.
The dicom data with 0.625-slice-thickness were input in the
soft ware (Surgicase 5.0, Materialize, Belgium). The alveolar
vertical distraction were simulated using the software to find
out the best vector of the distractor. In general aenesthesia
osteotomy and fixation of distracters were done. Distraction
started 7 days later 0.50.75 mm per day. Consolidation period
were finished after 12 weeks, distracters were removed and 24
dental implants (Replace groovy, Noblebiocare) were inserted.
Implantds were uncovered 16 weeks later and fixed prosthetics were delivered.
Results: With DO 612 mm of bone was gained and provided
conditions for rehabilitation woth dental implants. In our case
series, uneventful healing happened in 100% of the cases. In
any case no extra augmentation procedure was needed.
Implantation was done immediately after consolidation period.
All the implants were osteointegrated.
Conclusions and clinical implications: In all eight cases with
DO vertical deficiency of alveolar ridge were anatomically corrected. The using of the three dimensional software helps to
decide the vector of the distractor and the direction of the
new bone formation. The established height of the alveolar
ridge made the insertion of the implants possible.
257

Engineering
Impact of a concentrate of autogenous

mononuclear stem cells on bone regeneration
a pilot-study
Angelika Wildburger,1 Michael Payer,1 Robert
Kirmeier,1 Dirk Strunk,2 Natalie Etchart-lichtenstein,2
Sebastian Sauerbier3
1
Department of Oral Surgery and Radiology, Medical University

2
Graz, Graz, Austria, Stem Cell Research Unit, Medical

University Graz, Graz, Austria, 3Department of Oral and
Craniomaxillofacial Surgery, University Hospital Freiburg,
Freiburg, Germany
Background: Autogenous bone, with its osteogenic, osteoin-
ductive and osteoconductive properties, is still considered the

ideal grafting material by many surgeons (Hallman & Thor
2008). However, donor site morbidity is a major problem
accompanying boneharvesting techniques. Seeding bone substitutes with mononuclear stem cells (MSC) may result in
bone formation comparable with bone formation in regions
augmented with autogenous bone solely (Gutwald et al. 2009).
Bone marrow aspirate concentrated with a chair side centrifuge could help to avoid donor site morbidity and time-consuming and expensive cell proliferation procedures in a lab.
Aim: To evaluate histomorphometrically early bone regeneration (NB) after sinus floor augmentation comparing directly a
bovine bone substitute mixed with a concentrate of autogenous bone marrow stem cells and a bovine bone substitute
alone.
Methods: In a randomized, controlled split-mouth design,
seven consecutive patients (age 58 years, range 4772) with a
highly atrophic maxilla (residual bone height <3 mm) requiring bilateral sinus augmentation and implant treatment were
included. Before the augmentation procedure 60 ml of bone
marrow aspirate was harvested from the right posterior iliac
crest. At the test side augmentation procedure was performed
with a bovine bone mineral (Bio Oss) mixed with a concentrate of mononuclear stem cells (BMAC Harvest Systems). At
the control side Bio Oss was applied alone. Biopsies for histomorphometric analysis were taken navigated (ExpertEase System) 3 and 6 months after sinus augmentation at the planned
implant sites. Implants were inserted at the time of the
6 months biopsies.
Results: In a randomized, controlled split-mouth design, seven
consecutive patients (age 58 years, range 4772) with a highly
atrophic maxilla (residual bone height <3 mm) requiring bilateral sinus augmentation and implant treatment were included.
Before the augmentation procedure 60 ml of bone marrow
aspirate was harvested from the right posterior iliac crest. At
the test side augmentation procedure was performed with a
bovine bone mineral (Bio Oss) mixed with a concentrate of
mononuclear stem cells (BMAC Harvest Systems). At the
control side Bio Oss was applied alone. Biopsies for histomorphometric analysis were taken navigated (ExpertEase System)
258
3 and 6 months after sinus augmentation at the planned

implant sites. Implants were inserted at the time of the
6 months biopsies.
Conclusions and clinical implications: This limited pilot study
did not reveal any beneficial effect of a mixture of a stem cell
concentrate to a bovine bone substitute from a histomorphometrical point of view. However a larger study group could
possibly provide more significant data.

Engineering
Fourier analysis of human histology of

augmented bone after transplantation of stem
cells CD43+ incubated on allogenic scaffold.
Andrzej Wojtowicz,1 Piotr Bar,1 Sawomir Chaberek,4
Artur Kaminski,2 Ewa Olender,2 ElZbieta
Urbanowska,3 Jan Perek,1 Wiesaw WiktorjEdrzejczak,3 Karolina Szaniawska1
1
Department of Oral Surgery, Medical University Warsaw,

Warsaw, Poland, 2Central Tissue Bank, Medical University
Warsaw, Warsaw, Poland, 3Bank of Stem Cells, Medical
University Warsaw, Warsaw, Poland, 4Otwock Hospital Im.
Grucy, Otwock, Poland
Background: Bone augmentation for dental implant therapy is
successful when sufficient jaw bone quantity and quality is

confirmed. For bone augmentation we apply different methodology and different transplants. For standard bone augmentation which is well known and described in the literature - a
potent adjunct are autogenic bone marrow derived stem cells
methodology supported by biological science.
Aim: Morpho-histological analysis (Fourier and Fractal) of bone
induction after stem cells CD34+ transplantation, incubated
72 h before surgery on allogenic mineralized bone scaffold.
Methods: Five patients (2 female 4550, and 3 male 4060 y.o)
were selected for the bone augmentation surgery according to
the protocol approved by Bioethical Committee of Warsaw
Medical University. Patients with bone defects of
10 9 10 9 10 mm size, were selected. Bone marrow (10 ml)
was taken from the pelvis bone by aspiration biopsy. Stem
Cells 34+ were isolated and counted (2.24.2 9 10 6), then
incubated for 3 days on the allogenic cancellous mineralized
bone-scaffolds (deep frozen and irradiated by gamma radiation
3.3 KGray). After 3 days of incubation auto-allogenic bioreactor were installed into bone defects and stabilized by fixation screws. Bone biopsy was taken 6 months later (size 10
12 9 3 mm) with trephine for histology. Sirus Red staining
(F3BA) was done and sections were photographed in polarized
microscopy to enhance the birefringency of collagen in bone
trabeculae. One hundred and twenty-five pictures (25 randomized sections of each patients) were evaluated using Fourier
and Fractal analysis.
Results: Fourier analysis showed thicker bone trabeculae
induced after auto-CD34+ allo bioreactor transplantation.
The spatial distribution-direction of the newly formed bone tra-
beculae was similar to normal bone tissue. Old allogenic bone

tissue was almost completely resorbed. Fractal analysis and
fractal dimension were higher in newly formed bone tissue.
Conclusions and clinical implications: The stem cells were first
time incubated for 72 h on allogenic scaffold for instead of hip
bone donor sites as gold standard transplantation methodology. The use of allogenic-cancellous bone block combined
with incubated autogenic stem cells was listed between GBR
and GF (growth factor) methodology. The results are better
than when stem cells were implanted on DBBM scaffold after
10 min incubation only. The induced bone on allogenic bioreactor-scaffold is mature, but still younger than orthotopic
bone. The quality and quantity of newly form bone is sufficient for implants therapy, vertical dimension gain was
approximately 2.5 - 3.5 mm.

Engineering
Comparison of isoforms of BMPs 2, 4, 6 genes

expression in bone micro-biopsy-core after
mandible bone augmentation
Andrzej Wojtowicz,1 Artur Kaminski,2 Ewa Olender,2
Karolina Szaniawska1
1
Department of Oral Surgery, Medical University Warsaw,
Warsaw, Poland, 2Central Tissue Bank, Medical University
TICA 5.0 software. We compared the evaluated results using

the analysis of variance (ANOVA).
Results: It was found, that expression of m-RNA for BMP-2,
-4, -6 were different, highest for BMP2. The BMP2 expression
in cores after autogenic bone transplantation was three times
higher in comparison to BMP2 expression in cores after processed, deep frozen, irradiated allogenic bone chips transplant,
the BMP6 was lowest in all evaluated bone samples. The
BMPs isoformes expression in cores after use of DBBM (alone)
was not significantly higher than backgroud fluorescence.
Conclusions and clinical implications: Different isoformes of
BMPs are expressed in different manner in augmented bone in
all applied methods of GBR. It is postulated that these differences are important factors which determine duration of bone
healing and bone maturation in various methodologies, best
one of gold standard, good one of allogenic bone transplant
from tissue bank. The use of allo-transplant without iatrogenic additional surgical donor site procedure can be used
alternatively to autogenic bone. The bone induced after
DBBM seemed to be dead during its resorption and remodeling
for longer time.
60 Posters Tissue Augmentation and Engineering
Effects of soft-tissue augmentation as implant

pretreatment
Warsaw, Warsaw, Poland
Yutaka Yamada, Tetsuya Nishida, Shuichi Sato,

Koichi Ito
Background: Bone augmentation procedures are used for pre-
Division of Advanced Dental Treatment, Department of
prosthetic surgery as well as implanto-prosthetic methodology.

Differences in efficacy and duration of bone healing depends
on triad: osteoprogenitor cells activation, scaffold features and
growth factors synthesis. All of these factors can be processed
out of the body: stem cells isolates from the bone marrow,
scaffold as a part of autogenic or allogenic bone as well as
isolated, purified or synthetic human recombinant growth
factors.
Aim: In this study we measured the level of expression of
genes for three isoforms of bone morfogenetic proteins (BMP
2, -4, -6), whose role is crucial in bone induction, bone formation and bone/transplant turnover.
Methods: Seven samples of bone mandible chips were collected from healthy male patients (3545 years old), seven
bone chips (cores) after use of allogenic bone transplants, and
seven cores (microbiopsy) after DBBM application in mandible
deficiency as a pre-implants-GBR surgery. RT-PCR methodology was applied for evaluation of activity of the genes m-RNA
for BMP2, -4, -6. All bone tissue cores were taken out with
trephine 3 months after autogenic, allogenic bone chips and
DBBM granules transplantation into mandible bone deffect as
a part of implant surgery. The weight of the taken bone
micro-biopsy (cores) samples was 0.0870.208 g. Total RNA
was extracted using TRIzol reagent (Gibco BRL), the RNA pellet was dissolved in 25 l of sterile diethylpyrocarbonate-treated Mili-Q water and quantified spectrofotometrically at
260 nm. All statistical analysis was performed using STATIS-
Periodontology, Nihon University School of Dentistry, Tokyo,

Japan
Background: An adequatekeratinized mucosa around implants
is important. Mucogingival surgery around implants is generally performed after placing the implants, which complicates
implant therapy. Therefore, as pretreatment to simplify the
implant therapy, we performed a modified free gingival graft
in the edentulous area in one patient and a connective tissue
graft in another.
Aim: To evaluate the effectiveness of soft-tissue augmentation as implant pretreatment.
Methods: Case 1 was a 70-year-old male with generalized
severe chronic periodontitis who had four implants placed in
the right and left mandible molar regions. There was insufficient keratinized mucosa, and the mucogingival junction was
adjacent to the alveolar crest in both regions. Consequently, a
free gingival graft following vestibular extension using a splitflap technique was performed. The recipient site was prepared
with a partial thickness flap reflected with an alveolar crest
incision approximately 2 mm lingual from the mucogingival
junction and a mesiodistal longitudinal incision. The transplant was autografted to the edge of the alveolar crest side at
the recipient site. The reflected split flap was displaced and
sutured to the apical edge of the transplant. Case 2 was a 61year-old female with localized moderate-to-severe chronic
periodontitis and an all-ceramic bridge in a portion missing
259
from a left maxillary first premolar. Although there was sufficient keratinized mucosa, the alveolar crest was narrow and
Class I in Seiberts classification. There was also an approximately 3-mm Miller Class I recession at the adjacent cuspid
tooth. Therefore, a connective tissue graft was performed for
ridge augmentation and root coverage. Subsequently, the
patient changed her mind and requested implant placement.
Therefore, implants were placed, and the superstructures were
fixed in both cases. Both patients received maintenance care.
Results: These proposed techniques augmented the keratinized mucosa or ridge width at the residual ridge before
implant therapy. Generally, no scar tissue forms after soft-tissue grafts; the keratinized mucosa around the implants
exceeded 2 mm, and favorable peri-implant tissue was maintained.
Conclusions and clinical implications: The results suggest that
these techniques simplify implant therapy when there is
insufficient keratinized mucosa or ridge width around the
planned implant sites.

Engineering
The healing effect of platelet-rich fibrin on rabbit

calvarium wounds
Hyun-joong Yoon
Department of Oral and Maxillofacial Surgery, Yeouido St. Marys
Hospital, Seoul, Korea
Background: It is known that PRF has many growth factor like
PDGF-AB, TGF-B, VEGF, EGF, IGF-1. lots of studies proved

role of growth factors and Clark RA. et al argued that PRF was
useful in healing and regeneration of the soft tissue. however,
there are in short of studies about the clinical meaning of PRF
in jaw specifically, when injuriy of bone happens. thus, in this
study, we analyzed that what effect PRF, taken from rabbits
blood, can make in healing of the injured bone through histologic observation.
Aim: The purpose of this study was to evaluate the effect of
Platelet-Rich Fibrin (PRF) on the healing and regeneration of
rabbit calvarium wounds.
Methods: The right and left sections of the calvarium of nine
rabbits were exposed. In each rabbit, two circular bone defects,
one on each side of the midline, were prepared using a reamer
drill with a diameter of 7 mm and a depth of 3 mm. PRF were
prepared with standard protocols. Each experimental sites
received PRF and control sites were left filled with blood. The
animals were sacrificed at 1 (N = 3), 4 (N = 3) and 8 (N = 3)
weeks. The specimens were assessed for angiogenesis and
osteogenesis using vascular endothelial growth factor (VEGF)
immunohistochemical staining method and hematoxylin and
eosin (H & E) staining method.
Results: The percentage and the area of newly formed bone for
experimental sites were consistently greater than for control
sites at all sacrifice intervals. However, the difference between
experimental and control sites was gradually decreased. As
260
time passed, the amount of newly formed bone was progressively increased for experimental and control sites. The immunostaining intensity and thepercentage of positively stained
cells for VEGF in experimental group were greater than control group at week 1 post-surgery
Conclusions and clinical implications: PRF application improve
repair and angiogenesis on rabbit calvarium wounds and
increase the amount of newly formed bone, especially in the
early bony healing phase.

Engineering
A novel guided bone regeneration technique

Osama Zakaria, Marwa Madi, Shohei Kasugai
Tokyo Medical and Dental University, Tokyo, Japan
Background: Periosteal distraction osteogenesis (PDO) results
in supra osseous new bone formation however the invasion of

the created space with non-osteogenic soft tissue is a disadvantage. De novo supra osseous bone formation can be
obtained also using guided bone regeneration (GBR) in addition to elimination of soft tissue. However, this technique
requires excellent soft tissue management to avoid premature
membrane exposure.
Aim: Is to evaluate a novel osteogenesis technique that combines the occlusiveness of GBR and flexibility of the Periosteal
distraction techniques.
Methods: Eight rabbits were used. The expansible GBR device
is composed mainly of a secluding silicone membrane and an
elevation component. The calvarial bone was exposed then
skin and periosteum were reflected followed by cortical Surface activation. Components of the device were fixed over the
activated area (21 9 15mm) then flab was sutured. One week
later, an elevating screw was inserted and activated in a rate
of 1 mm/day for 5 days causing the overlying silicone membrane to expand gradually and finally take a shape of a tent.
Group1 animals (n = 4) were sacrificed after 2 months consolidation period followed by group2 (n = 4) at 4 months. Specimens were scanned using micro Computerized Tomography
(lCT) then images were analyzed using (3D) image analysis
software from which volume of newly created space (Vs) and
new bone tissue volume (Bv) were obtained. lCT images were
analyzed to obtain the average height of the original bone (Bo),
average height of augmented bone (Ba) and maximum height
of titanium plate (Th). Specimens were embedded in polyester
resin (Technovit 7200) and then toluidine stained before observation under light microscope. MannWhitney U-test was
used to compare (Bv) and (Ba) between the two groups.
Results: Histologically considerable amount of intra membranous bone trabeculae were observed. Micro CT image analysis
showed that the original bone thickness increased by 2.21
times in group1 and 2.34 times in group 2 and considerable
amount of de novo bone has been created (68.2 22 mm3
ingroup1 and 70.3 14 mm3 in group 2) in the sizeable created secluded spaces (207.1 31 mm3 in group1 and
202 21 mm3 in group2) There was no Statistical significant

difference (MannWhitney U-test) between the two groups
regarding (Bv) or (Ba).
Conclusions and clinical implications: Employing this technique clinically may offer an economic and simple treatment
for alveolar bone deficiency in vertical and horizontal aspects.
Also it creates an in vivo bone bioreactor in humans as a

resource of easily harvestable autogenous bone for auto-grafting with little morbidity.
261

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494 Posters Tissue Augmentation and

The use of Platelets rich fibrin (PRF) in

and its systematic use during covering bony defect above

495 Posters Tissue Augmentation and

Implants in a patient with bilateral cleft lip and

lip and palate represents a clinical challange. Conventional

496 Posters Tissue Augmentation and

497 Posters Tissue Augmentation and

Mineralized human allograft for the preservation

Marco Clementini,1 Gianluca Furlani,1 Giulia

Fondazione IRCCS Ca` Granda Fondazione policlinico, Milano,

University Tor Vergata, Rome, Italy, 2University of Modena and

tooth extraction could be unfavourable for future implant

ridges reconstruction are described in literature, such as

498 Posters Tissue Augmentation and

A novel cellulose hydroxyapatite scaffold for

Lithuanian University of Health Sciences, Kaunas, Lithuania,

University of Porto, Porto, Portugal, 4CICECO, University of

Aveiro, Aveiro, Portugal

499 Posters Tissue Augmentation and

Homogenous bone block for the reconstruction

degree in Implantology by University of Sagrado Coracao, Bauru,

stable, long-term esthetic final result. Homogenous grafts are

500 Posters Tissue Augmentation and

Adsorbed Periostin protein on titanium surfaces

ferentiate into the right phenotype to regenerate the tissue

complete DMEM with 10% Fetal Bovine Serum. Cell adhesion

501 Posters Tissue Augmentation and

Initial density affects the resorption of bone

University of Parma, Parma, Italy, University of Bologna,

(998 232 HU). The mean density variation was 9% in the

502 Posters Tissue Augmentation and

Platelet rich fibrin (PRF) as a matrix for human

Bologna, Italy, 3University of Modena and Reggio Emilia, Modena

and Reggio Emilia, Italy

Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany,

Department of Oral and Maxillofacial Surgery, University

Institute of Medical Informatics and Statistics, University

Background: Bone graft composition and microarchitecture

Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany,

strongly affect their biological behavior. Density represents a

Department of Organic Chemistry, University of Ghent, Ghent,

Belgium, Gent, Belgium

is an extracellular matrix in which osteoblastic cells can

503 Posters Tissue Augmentation and

Keratinized tissue augmentation by means of a

6 months showed less than 20% contracture (considered as

504 Posters Tissue Augmentation and

Effect of low level laser irradiation on bone

Odontostomatologic Laser Therapy Center, Florence, Italy,

Background: A good level of keratinazed tissue is not proven

to effect implant success rate, but is important for oral

Preclinical and Clinical Pharmacology,, Florence, Italy,

Physiological Sciences, Florence, Italy, 5Haematology, Placental

Blood Bank, Careggi Hospital, Florence, Italy

defects or loss of teeth of the oral cavity is an important

Hes-1 were evaluated in MSCs cultured in the absence or

placed in the alveolar mucosa facial or lingual to the tightened

505 Posters Tissue Augmentation and

506 Posters Tissue Augmentation and

Thickening of peri-implant mucosa using

Clinical and tomographic analysis of the increase

Dusan Groselj,1 Astrid Razem,2 Mateja

MEGFID d.o.o., Ljubljana, Slovenia, 2ARDENS d.o.o., Koper,