r.t.r. clinical cases studies package - septodont · 2019. 2. 27. · sinus floor augmentation with...

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Full resorption... strong new bone formation

R.T.R.

Case StudiesSeptodont

CollectionSeptember 2018

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Bone AugmentationBiomaterials for bone regeneration in oral surgery: A multicenter study to evaluate the clinical application of “R.T.R.” ............................................................................................................... 04P. Brunamonti Binello, G. Galvagna, M. Galli, M. Labanca

Use of ß-tricalcium phosphate for bone regeneration in oral surgery ......................................................... 12G. Galvagna, P. Brunamonti Binello, M. Galli, M. Labanca

ß-tricalcium phosphate used with onlay graft for horizontal bone augmentation yielded preferable result: a case report................................................................................................. 22Yaqian Chen, Qingqing Wu, Yi Man

Post-extraction sockets Bone regeneration with ß-tricalcium phosphate (R.T.R.) in post-extraction sockets .................. 27O. H. Arribasplata Loconi

Use of R.T.R. and PRF as filling material in post extraction sockets ......................................................... 36P. González, O. González, C. Zenteno, J. Urrizola

Alveolar Ridge PreservationAlveolar Ridge Preservation With Alloplastic Material ........................................................................................... 40Ana I. Coello Gómez, Selene P. Navarro Suárez, Daniel Torres Lagares, Jose Luis Gutiérrez Perez

Clinical case of alveolar ridge preservation with alloplastic material: Results at 6 months ................................................................................................................................ 46Dr. S. P. Navarro Suárez, Dr. D. Torres Lagares, Dr. J. L. Gutiérrez Pérez

Alveolar preservation with R.T.R................................................................................................................................................. 50Dr Gabriela Vilar Pineda

Periodontal defectsR.T.R. and aggressive periodontitis ............................................................................................................................................. 59D. Bouziane, K. L. Makrelouf, M. Bouziane

Alloplastic Grafts - Beta-tricalcium phosphate ................................................................................................................. 67Mario Ernesto García-Briseño

Periodontal intraoseous defects and post-extraction compromised socket. Treatment with Beta Tricalcium Phosphate..................................................................................................... 74Dr. Mario Ernesto García Briseño

Sinus LiftSinus Floor Augmentation with ß-Tricalcium Phosphate (R.T.R. Septodont)................................... 79Mario Ernesto García-Briseño

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Content


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International Literature about bone regenerationin implant dentistry describes many differentavailable surgical techniques and the followingare the principal:• Guided Bone Regeneration (G.B.R.)• Bone Grafting• Osteogenic Distractions Each of the above mentioned methods, whilepresenting different and precise applicationlimits (mostly related to the type of defect and

the surgical technique), turned out to be predic-table if done correctly.(3)

The Literature data, then, show how - osteogenicdistractions aside - the use of a biomaterial(regardless of its origin, whether animal orsynthetic) is helpful if not indispensable to theattainment of an adequate clinical outcome.(4)

Finally, the use of semi-permeable barriers -whether or not absorbable membranes - ratherthan metal grids, in order to maintain a suitable

Biomaterials for bone regenerationin oral surgery: A multicenter study to evaluate the clinical application of“R.T.R.” (ß-Tricalcium Phosphate)Paolo Brunamonti Binello: Consultant Professor, University of GenoaGiuseppe Galvagna: Private practice, Catania, ItalyMassimo Galli: Private practice, Pistoia, ItalyMauro Labanca: Consultant Professor in Oral Surgery and Anatomy, Milan, Italy

In Literature there isn’t any conflicting data about the clinical results obtained in OralSurgery for bone regeneration using Biomaterials of either animal or synthetic origin.(1)

What is the most important, however, is the creation of a microenvironment suitable forthe proliferation and differentiation of hard tissues, such as to successfully promote theregeneration of new bone at the implant-prosthetic purposes.(1-2)

For this reason, therefore, the Authors always prefer the use of synthetic materials withreduced risk of inflammation and complete absence of potential cross infections.(1)

The Goal of this study is, therefore, to illustrate - through a case series - short term resultsof a multicenter research on bone regeneration in Oral Surgery by using an heterologousfilling material that consists of ß-Tricalcium Phosphate, called R.T.R.

Introduction


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R.T.R. (ß-tricalcium phosphate)

space, has proved indispensable in G.B.R., whileit is still extremely discussed in other regenerativetechniques.(5)

In fact, when we speak about Biomaterials inRegenerative Oral Surgery it is appropriate tomake a distinction between the followingelements:- Semi-permeable membranes: they allow the

stabilization of cloth and the selection of celllines that will colonize the bone defect (spacemaintainer = maintenance of biological space).

- Filling material: Support the membrane andact as a "scaffold" for the migration, growthand differentiation of pre-osteoblasts intoosteoblasts.

To contribute to the regeneration process, hereare the following basic mechanisms of Osteo-

genesis, understood as a budding center ofdeputies to the new bone genesis: - Osteoinduction: stimulation of the differentiation

of mesenchymal cells in preosteoblasts.- Osteoconduction: biological scaffold as a support

to new cells in the differentiation process.

It is deduced that the new bone tissue formationoccurs if the following organic conditions exist:- Availability of mesenchymal cells capable of

differentiating following the osteoinductive input- Presence of osteoinductive input ("Osteoin-

ductive Boost"), which initiates the differentiationof mesenchymal preosteoblasts in osteoblasts

- Existence of an osteoconductive environmentthat promotes the colonization and proliferationof graft.

Except for autologous bone, on the fundamentalconcepts of Osteogenesis, remains today stillopen the debate as to which type of currentlyavailable bone grafting material is the best.(6)

Given that, the Authors have carried out a multi-center research about clinical application of asynthetic filler (already known for years on themarket) based on ß-Tricalcium Phosphate forbone regenerative purposes, called “R.T.R.”(Resorbable Tissue Replacement).(6)

The Ca3(PO4)2 powder (treated with naphthaleneand subsequently compacted by sintering) formthe ß-tricalcium phosphate, with macropores ofa diameter between 100 and 300 microns ideal,that is, for the Osteoconduction.(6)

This heterologous biomaterial, once placed, iscompletely absorbed in 6 or 9 months, andreplaced by new bone.(6-7)

Recent studies on large crestal defects show asignificant increase in the regeneration with ß-Tricalcium Phosphate already after 2 weekscompared to the other control sites, therebyproving the effectiveness of this filling material.(7)

During resorption, in addition, ß-Tricalcium Phos-phate provides with Ca ions and phosphate

into the site of regeneration: this creates anideal ionic concentration with an alkaline pH,which stimulates the activation of alkaline phos-phatase enzyme, which is essential to theossification process.(6-8)

Then, all resources of this study and the attentionof the authors are focused on the use of ß-Trical-cium Phosphate called “R.T.R.” basically becausethis synthetic biomaterial would possess - as aprerequisite - all the features that a genericfilling material should have -with the exceptionof Osteinduction.(6-7-8)

These characteristics may be summarized asfollows:- High biocompatibility and minimum autoimmune

response- Bio-inert (absence of local inflammatory reac-

tion)- Ideal time of resorption for the type of bone

defect- Total reabsorption - Excellent osteoconductivity- Good packaging- High handling during surgery- Absolutely no risk of cross-infection transmission


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In particular, since “R.T.R.” is completely resor-bable over a period of time, reasonably usefulfor important bone defects resolution, the authorsthink “R.T.R.” is particularly appropriate for allregenerations conducted for the purpose of

implant-prosthetic rehabilitation, in contrast withmany other filling materials that do not resorbcompletely - and allow only a repair instead of ahealing of the bone defect.(8-9)

Materials and methodsThis multicenter Study provides for the regene-ration of bone tissue with ß-tricalcium phosphate”R.T.R.” in patients with a residual bone defectof the maxillary and with implant-prostheticrehabilitation purposes.The selection of patients is randomized. However,in order to standardize the number of cases,this random selection requires that patientshave the following basic requirements:- Aged between 20 and 60 years- Either male or female- Non-smokers - In good general health- Having at least a residual crestal bone defect

Regarding the type of defect, it is deliberatelyexcluded to standardize the same, in terms ofmorphology and etiopathogenesis, in order toverify the regenerative effectiveness of “R.T.R.”in different conditions of bone atrophy (and,therefore, of different “regenerative thrusts”).It is, therefore, decided to treat the followingclinical situations:- Post-extractive sites- Bone regeneration around implants placed

in areas with deficiencies in bone or post-extraction

- Overall G.B.R. (sinus lift or major bone defects)

Case seriesThe Authors, from 4 different cities and fromdifferent working situations (private practice,hospital and private clinic) have treated12 patients with the following bone defects:- N 3 peri-implant defects- N 2 sinus floor lifts- N 4 post extractive sockets - N 3 bone defects of various types

In all cases, the patients were subjected to anti-biotic therapy with 200 mg / day of Doxycycline(in 2 doses daily beginning the day beforesurgery up to 8 days after the intervention), todaily repeated rinses with chlorhexidine andtherapy with FANS as needed (Ibuprofen 800 mg/ day in single-dose).

Case Report no.1The first is a case report of a 54-year-old malepatient, in good health general conditions, witha mandibular residual cyst in area 46. (Fig. 1-2-3)In accordance with the patient, we opted for anintervention of Partsh II, filling the remainingcavity with R.T.R. granules without using semi-

permeable membranes. (Fig. 4-5-6-7-8)About 6 months after the first surgery, the nextstep will involve the placement of one implant.The local objective examination and routineradiographic examination showed a good healingshort-term. (Fig. 9-10-11)


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Fig. 1-2-3: Mandibular residual cyst in area 46.

Fig. 4-5-6-7-8: Intervention of Partsh II and filling of the remaining cavity with R.T.R. without using semi-permeable membranes.

Fig. 9-10-11: The local objective examination and routine radiographic examination showed a good healing short-term.


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The second case report is a 45-year-old femalepatient, in good general health conditions withedentulous in area 25-26 and progressiveatrophy of the corresponding alveolar process.(Fig. 12-13)In accordance with the patient, by full-thicknessmucosal flap in the area 25-26, we opted for atranscrestal sinus floor lift with a R.T.R. graftand simultaneous placement of two fixtures.In this case R.T.R. has been used also as afilling material around implants contextually.

For this case the syringe form of R.T.R. hasbeen chosen.The fixtures had a good primary stability, equalto about 60 newtons. (Fig. 14-15)The subsequent exposition of the implants andthe beginning of the prosthetic phase will bemanaged about 6 months after sinus lift proce-dure.The good health of the superficial soft tissuesand surveys Rx screening show the excellenthealth of deep tissues in short term. (Fig. 16-17)

Fig. 12-13: Edentulism in area 25, 26 with partial atrophy of the alveolar process residue.

Fig. 14-15: Full-thickness mucosal flap in the area 25-26 and transcrestal sinus floor lift with a R.T.R. graft to a simultaneous placement of twofixtures. R.T.R. has been used also as a filler around implants.

Fig. 16-17: The good health of the superficial soft tissues and surveys Rx screening show the excellent health of deep tissues in short term.

Case Report no.2


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Case Report no.3The third case report involves a 52-year-oldfemale patient, in good general health conditions,who has been subject to avulsion of the elements16 and 17, because they were irreparablycompromised and extremely symptomatic.(Fig. 18-19-20)In area 16, for regenerative purposes, has been

executed a graft of R.T.R., presented in a conewith collagen. (Fig. 21-22-23-24-25)About 6 months following R.T.R. graft will bepositioned an implant.Also in this clinical case as in the others thelocal objective examination and the Rx screening showed an excellent recovery in the short term.

Fig. 24-25: Immediate post op clinical and radiological situation.

Fig. 21-22-23: In area 16, for regenerative purposes, has been executed a graft of R.T.R.

Fig. 18-19-20: Avulsion of the elements 16 and 17 due to a severe periodontal defect.


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DiscussionThe post-surgical follow-up in the short term(which provides an objective local examinationand Rx control after 8 days and also in followingweeks after the first surgical step) showed thatin all cases treated were found the followingitems:• Good immediate healing of superficial soft

tissues• Excellent radiographic condition of deep tissues• Absence of autoimmune reactions• Absence of local reactive inflammation• Absence of excessive bleeding

The authors also confirm that R.T.R. material,besides having a packaging extremely functional,has expressed high qualities of practicality andmanageability during the surgical procedure, inits mode of use, application and compaction (inall the forms of packaging).

The on-going research, currently in the initialphase, involves a series of stages, in which willalso be performed (if and where possible) theimplant-prosthetic rehabilitation of bone defectstreated and, if possible, a histological evaluationsuitable to document the degree of absorptionand regeneration.(10-11)

ConclusionThe interesting initial and partial results obtainedto date are encouraging for the authors tocontinue the study in progress.The goal remains to propose a predictable thera-peutic solution, though alternative and not areplacement of the other existing and fullydescribed in the Litterature. (12-13-14-15-16)

Authors (left to right)Mauro Labanca: From 2001 to 2005: Creator and Director of the very first Italian course“Anatomical surgery with Cadaver lab”. From 2006 up to date: Director of the course of“Anatomical surgery with Cadaver lab” at the Institute of Anatomy at the University of Wien,Austria. 2006: Creator and Director of the first Master of Marketing and Communications inMedicine and Private Dentistry at IULM University (Libera Università di Lingue e Comunicazione) inMilan, Italy. From 2007 up to date: International Consultant in Dentistry for MEDACorp, LeerinkSwann LLC Boston, MA, USA. From 2007 up to date: Consultant Professor of Oral Surgery in thedepartment of Dentistry at “Vita e Salute University” - S. Raffaele Hospital - Milan, Italy. From 2008up to date: Consultant Professor of Anatomy in the Department of Medicine at the University ofBrescia, Italy. 2009: Co-Founder and vice President of the Italian Society for the study of Oro-Facial Pain (SISDO). 2011: Founder and President of the “Labanca Open Academy” (LOA) devotedto the improvement of all aspects of Dentistry. Created to have an open network among allparticipants of his courses. From 2012: Visiting professor at the Periodontology Department of the“Universitat Internacional de Catalunya”, Barcellona, Spain.Paolo Brunamonti Binello: Consultant Professor, University of Genoa. Executive Doctor“Galliera Hospital”, Genoa, ItalyGiuseppe Galvagna: Private practitioner, Catania, ItalyMassimo Galli: Oral surgeon and private practitioner, Pistoia, Italy


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References

01. Labanca M, Leonida A, Rodella FL Natural or synthetic biomaterials in Dentistry: Science and ethic ascriteria for their use. Implantologia 2008; 1:9-23

02. Nociti FH Jr, Machado MA, Stefani CM, Sallum EA, Sallum AW. Absorbable versus nonabsorbablemembranes and bone grafts in the treatment of ligature-induced per-implants defects in dogs. Part I. Aclinical investigation. Clinical Oral Implants Research 2001;2:115-120.

03. Hardwick R, Scantlebury T, Sanchez R, Whitley N, Ambruster J. Membrane design criteria for guided boneregeneration of the alveolar ridge. In: Buser D, Dahlin C. Schenk RK, eds. Guided bone regeneration inimplant dentistry. Chicago, IL: Quintessence. Ist edition, 1994;101- 136.

04. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plasticand Reconstructive Surgery 1988;81:672-676.

05. Hockers T, Abensur D, Valentini P, Legrand R, Hammerle CH. The combined use of bioreasobablemembranes and xenografts or autografts in the treatment of bone defects around implants. A study inbeagle dogs. Clinical Oral Implants Research 1999;6:487-498.

06. Coetzee AS. Regeneration of bone in the presence of calcium sulfate. Arch Otolaryngol 1980;106.405-409.

07. Irrigary J. A study of atomic elements diffusion in coral after implantation in vivo. Publication de BiomatBordeau, France 1987:241-248.

08. Guillemin G. The use of coral as bone graft substitute. Journal of Biomedical Materials Research1987;21:557-567.

09. Gielkens PF, Bos RR, Raghoebar GM, Stegenga B. Is there evidence that barrier membranes prevent boneresorption in autologous bone graft during the healing period? A systematic review. Int J Oral MaxillofacImplants 2007;22(3):390-398.

10. Raymond AY, Sotirios V. Comparative evaluation of decalcified and non-decalcified freeze-dried boneallograft in Rhesus monkeys. I. Histologic findings. Journal of Periodontology 2005 Jan;76(1):57-65.

11. Sommerland S, Mackenzie D, Johansson C, Atwell R. Guided bone augmentation around a titanium bone-anchored hearing aid implant in canine calvarium: an initial comparison of two barrier membranes. ClinImplant Dent Relat Res 2007;9(1):22-33.

12. Maeda H, Kasuga T. Control of silicon species released from poly(lactic acid)-plysiloxane hybridmembranes. J Biomed Mater Res A 2007; [Epub ahead of print].

13. Mattout P, Mattout C. Conditions for success in guided bone regeneration: retrospective study on 376 implantsites. Journal of Periodontology 2000;12:1904-1909.

14. Chou AM, Sae-Lim V, Hutmacher DW, Lim TM.: Tissue engineering of a periodontal ligament-alveolar bonegraft construct. Int J Oral Maxillofac Implants 2006;21(4):526-534.

15. Kohal RJ, Hurzeler MB. Bioresorbable barrier membranes for guided bon regeneration around dentalimplants. Schweiz Monatsschr Zahnmed. 2002;12:1222-1229.

16. Hartman GA, Arnold R.M, Mills MP, Cochran DL, Melloing JT. Clinical and histologic evaluation of inorganicbovine bone collagen with or without a collagen barrier. International Journal Periodontics RestorativeDentistry 2004;2:127-135.


In order to obtain effective bone regenerationusing natural or synthetic fillers, a series offavourable conditions must occur that allow thebody to perform the bone growth (15) as follows:- presence of a blood clot with a high concen-

tration of mesenchymal stem cells (MSC)capable of evolving in the osteoblast line andof endothelial cells forming a rich vascularnetwork

- presence of vital bone tissue, from whichosteogenic and angiogenic cells originate

through adequately prepared surrounding bone(cortical perforation)

- stabilization and maintenance of volume under-neath the membrane

- protection of blood clot with a membrane,with the function of the stabilization of theclot, protecting growing vascular structuresand blocking the migration of epithelial cells,which proliferate faster than bone cells.

In 1980 Nyman and Karring first introduced theconcept of guided tissue regeneration (GTR) of

Use of ß-tricalcium phosphate for bone regeneration in oral surgeryA multicenter study to evaluate the clinical applications of R.T.R. (Resorbable Tissue Replacement) Giuseppe Galvagna: Private practice, Catania, ItalyPaolo Brunamonti Binello: Consultant Professor, University of GenoaMassimo Galli: Private practice, Pistoia, ItalyMauro Labanca: Consultant Professor in Oral Surgery and Anatomy, Milan, Italy

Introduction

In prosthetic implant rehabilitation, loss of bone volume in atrophic maxillae is one of themajor problems faced by surgeons in their clinical practice. In the presence of horizontaland vertical bone defects, atrophic ridges need to be restored to make them suitable forimplant placement and for restoration of masticatory and aesthetical functions.For this reason, in recent years the term “GBR” has been closely associated with theconcept of prosthetically guided implantology.The purpose of this study is to demonstrate the osteoconductive properties of syntheticbiomaterials, particularly ß-tricalcium phosphate or R.T.R., and its benefit for a suitable GBR.

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periodontal tissues, showing that the cells ofsoft tissue can grow faster than bone tissue (10).Thus, based on the results obtained, the migrationof soft tissue cells above the implanted materialmust be stopped, thereby blocking migrationwithin the porosity of the same material, thuspromoting osseointegration rather than fibroin-tegration. The main characteristic of a membraneshould be semi-permeability, i.e. the presence ofporosity approximately 22 microns in diameter.Initially, a thin vascular network and a primaryfibrous osteoid tissue -also called primary spon-giosa- will begin to form within the clot. Thelatter is later mineralized thanks to osteoblaststhat cover its surface, forming a new poorlycalcified cortical bone.The process stops when intertrabecular spacesnarrow due to the formation of new bone tissue,until they reach the characteristic dimensionsof Havers channel which, along with concentriclamellae, originate primary osteomas. All thisoccurs during the first 3-4 months, thoughactual bone remodelling requires more time, asit creates secondary spongiosa.Research conducted by Hämmerle in 1996 (11)on human subjects confirmed what hadpreviously been observed in animals, i.e. in thepresence of large bone defects, regenerationcan be limited to the more peripheral areas ofthe defect, while less activity is observed in thecentral area, where granules of biomaterialremain over time, though less frequently whentricalcium phosphate is used. The process ofossification always starts from the walls of thedefect toward the center of the clot, along thenewly formed vessels.A number of studies clearly describe the rege-nerative ability of autologous bone comparedwith synthetic biomaterials, but unfortunatelynot without negative aspects. Indeed, collectionfrom the donor site is very often painful for thepatient; additionally, this results in longer surgicalprocedures and postoperative pain ; finally, theimplanted material has a high degree of resorption(not a negligible factor).The materials used for bone regeneration aregrouped into: Autogenous bone, allogenic bone,xenogenic bone, alloplastic bone.

Graft biomaterials

The alloplastic biomaterials available on themarket represent an excellent alternative toautologous bone graft and are classified intotwo large groups: bioinert and bioactive, accor-ding to their interaction when they come intocontact with the receiving site.The main requirement of a synthetic biomaterialis to have a surface porosity that must promotecolonization and development within its structure.These porosities must measure between 200/400microns in diameter (Lynch et al., 2000; Bauerand Muschler, 2000). Synthetic biomaterialshave been the subject of many studies, thoughtheir long term results have not always beenconsidered. (1-2-3)Today, osteoblastic cells or bone morphogeneticproteins (BMP obtained with in vitro cultures)can be added to a graft material (4-5) to enhanceits osteoinductive and osteoconductive abilitiesand therefore reduce the time required for cellscolonization. (6-7-8)Among alloplastic biomaterials, ß-tricalciumphosphate is the one that mostly displays astable bond with bone neoformation; indeed,its characteristics have made it suitable foruse in orthopedics since the early 1900s. Inthe presence of H2O it becomes instable,turning into hydroxyapatite, and this characte-ristic makes it suitable as an osteoconductivematerial (Coetree, 1980, De Leonardis andPecora, 1999; 2000).ß-TCP is characterized by a lower Ca/P ratio,which makes it more soluble than natural apatite.The Beta form is commonly obtained by mixingcalcitis (CC) and dibasic calcium phosphateanhydrous (DCPA). The product obtained israpidly cooled, and Alfa-TCP is obtained. Conver-sely, extended repeat baking at 800/950°Cresults in the beta form (9-12-13).Multiple studies conducted on the TC and boneinteraction have shown that histological exami-nation at four months shows an initial boneneoformation in the intergranular spaces and inthe surface porosity that helps guided boneformation. Indeed, the granules are reabsorbedby phagocytosis, releasing Ca/Mg and phos-


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phates in the surrounding bone tissue, therebyactivating alkaline phosphatase, a key ossificationprocess. Between 6 and 18 months, fibroblastsbegin invading the biomaterial, activating theextracellular dissolution process which endswith the calcification phase. If this should occursooner, graft integration, rather than biodegra-dation, would happen. (5-6-7-8).

R.T.R.

Synthetic, biocompatible and totally resorbable99% pure tricalcium phosphate bone replace-ment, available in granules and in a cone shape,for regeneration in periodontal defects, implant,post-extraction bone defects and bone lesionsfollowing endodontic surgery.

The micro and macro-porous R.T.R. structure,with macropores measuring between 100 and400 µm and micropores measuring less than10 µm.These morphological characteristics allow excel-lent osteogenic cell in-depth colonization andeasy compacting.

Unlike hydroxyapatite, R.T.R. is progressivelyand totally reabsorbed, thereby releasing calciumand phosphate ions that participate actively inthe formation of new bone tissue. Over a periodof time between 6 and 9 months, which mayvary according to the patient’s physiologicalresponse, while stimulating bone regeneration,R.T.R. is progressively reabsorbed, leaving spacefor bone neoformation.

Indications: • Post-extraction sites• Filling post-extraction sites to maintain the

dimensions of alveolar bone • Implant defects• Sinus lift procedure• Reconstruction of peri-implant defects• Filling periodontal pockets with two or more

walls• Residual cavities after oral surgery (like cyst)• Filling defects after apicectomy• Alveolar filling following extraction of impacted

teeth.

We conducted a multicenter study to evaluatethe clinical application of R.T.R. (ß-tricalciumphosphate).

This study examines the regeneration of bonedefects with R.T.R. (ß-tricalcium phosphate) inpatients eligible for prosthetic implant rehabili-tation. Patients were randomly selected,according to the following key criteria:- aged between 20 and 60 years - either male or female- non-smokers- in good general health- having at least one crestal bone defect (no

morphology and etiopathogenesis restrictions).

The cases treated were identified in the followingclinical situations:- Post-extraction sites- Bone regeneration around implants placed in

areas with bone loss or post-extraction.- GBR (sinus lift or major bone defects).In all cases, patients received antibiotic therapywith 1 gr every 8 h of Amoxicilline plus ClavulanicAcid (starting 24 hours before surgery up to day5 post-surgery), repeated daily rinses with chlo-rhexidine and therapy with FANS (ibuprofen800 mg/day in single dose), as necessary.

Materials and methods


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Case Report no.1Patient: Female Age: 30History: odontogenic cyst in maxillary bone at 2.1. Cyst was removed in October 2013. Vertical guided regeneration with resorbable membrane andR.T.R. was performed. Implant placement: bone peak follow-up intraoral X-ray in consecutivemonths. 2nd surgery ISQ value: 61.

Fig. 1-4: Different projections of radiographic C.T images show the large bone defect in site 2.1. Fig. 5: Temporary prosthesis to cover thecosmetic defect.

Fig. 6: X-ray image beforegrafting.

Fig. 10: The ISQ test confirms a good stability of the implant.

Fig. 7: X-ray image after 5 months. Fig. 8: X-ray after insertionof the implant.

Fig. 9: The local objectiveexamination and routineradiographic examination showeda good short-term healing.

Fig. 11: To obtain a good aesthetics of the final prosthesis isimportant to condition the soft tissue with the healing screws thatfavors the emergence profile.


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Case Report no.2Patient: female Age: 60 History: large cyst in upper maxillary bone extending from 2.2 to 1.1.The cyst was removed and the cavity was filled with R.T.R. enhanced with PRGF (platelet-enrichedplasma) and simultaneous placement of five implants was also performed.

Fig. 12-13: Presence of large cysts of 2.1. The oral cavity examination shows a poor oral hygiene.

Fig. 14-15: Removal of the cyst; it is veryimportant to remove all residual epithelial.

Fig. 19-20: During the same surgery were included five implants. Fig. 21: X-ray control after five months.

Fig. 16-17-18: Filling the bone cavity with granular R.T.R.


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Case Report no.3Patient: femaleAge: 50 History: severe atrophy of the alveolar ridge, upper right jaw, affecting the area of 1.3, 1.4, 1.5, 1.6.These teeth were extracted and the alveolar ridge was reconstructed with R.T.R., covering biomaterialwith Tabotamp (oxidized cellulose).

Fig. 22-23: Resorption of the alveolar process caused by periodontal disease. The local examination shows the class III mobility of the teeth.

Fig. 24-25-26: Resorption of the alveolar process caused by periodontal disease. The local examination shows the class III mobility of the teeth.

Fig. 27-28: Use of Tabotamp to cover thegraft.

Fig. 29-30: The local examination after 10 days.

Fig. 31-32: The radiographic image after 4 months showed an increase in the verticaldimensions.


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Case Report no.4Patient: femaleAge: 30History: root fracture of 1.6, previously treated with root canal treatment and large crown compositereconstruction. The roots were carefully extracted, and an implant was placed, using the interadicularseptum bone and by performing an elevation of the maxillary sinus with osteotomes. The alveoliwere filled with R.T.R. and covered with a collagen membrane.

Fig. 33-34: Fracture of the first molar with the insertion of implant with post-extraction procedure.

Fig. 35-36-37: Extraction was performed with piezosurgery technique to preserve the alveolar bone.

Fig. 38-39-40: The gap was filled using R.T.R.-size cone.

Fig. 41-42: The intraoral examination and radiographic examination after 4 months showed good integration of the implant.


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Case Report no.5Patient: femaleAge: 64History: loss of 2.2 and 2.3 due to trauma.CT revealed a significant resorption of buccal vestibular alveolar process.Two implants were placed (measuring 3.3 mm in diameter and 13 mm long) and the gap was filledwith R.T.R.Re-opening was done after 5 months and evaluation of osteointegration with Osstel. 2.2 showed a value of 22-ISQ, and 2.3 –ISQ 64.

Fig. 43-44-45: Severe post-traumatic atrophy of the alveolar process in place 2.2- 2.3.

Fig. 48-49: The gap between the two margin bone was filled withphosphate-tricalcium R.T.R.

Fig. 46-47: Insertion of two implants with “split-crest” surgicaltechnique.

Fig. 50: X-ray control after 4 monthsshowed a good bone density.

Fig. 51-52: The intraoral examination doesappreciate a good recovery and an increasein bone volume.

Fig. 53-54: The ISQ value confirms a goodosseointegration.


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ConclusionBased on the results obtained in the short term,the authors confirm the excellent properties ofR.T.R., both in the first weeks of healing and inthe following months, and they consider it anexcellent alternative to autologous bone grafts. No inflammatory reactions or loss of bonevolume evaluated clinically and radiographically

occurred in any of the cases examined. Themost encouraging data came from the obser-vation of the compactness and density of thebone neo-formation, which easily allowed theplacement of implants with high ISQ valuesboth during and after the placement of R.T.R.graft.

Case Report no.6Patient: femaleAge: 55History: residual cyst at 3.6. To proceed to prosthetic molar rehabilitation with an implant, the cystwas extracted and the cavity was filled with R.T.R.; after a 4-month period for bone regeneration,the implant was placed.

Fig. 55-56: The C.T. examination beforesurgery showed a residual cyst.

Fig. 57-58: After having removed the cyst,to speed up the healing time, the cavity hasbeen filled with R.T.R. granules.

Fig. 60: X-ray at 3 months.

Fig. 59: Wound at 30 days.


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Authors (left to right)Giuseppe Galvagna: Dental practitioner, Catania, ItalyPaolo Brunamonti Binello: Consultant Professor, University of Genoa. Galliera Hospital,Genoa, ItalyMassimo Galli: Oral surgeon, dental practitioner, Pistoia, ItalyMauro Labanca: Professor of Oral Surgery and Anatomy, Milan, Italy

References01. Labanca M., Leonida A., Rodella FL: Natural synthetic biomaterial in Dentistry: Science and ethics as

criteria for their use. Implantologia 2008; 1:9-23

02. Ohgushi H, Caplan AI: Stem Cell Technology and Bioceramics: From Cell to Gene Engineering. J BiomedMater Res 48(6): 913-927, 1999

03. Anselme K: Osteoblast adhesion on biomaterals. Biomaterials 2000 Apr; 21(7):667-81.

04. Toquet J, Roahanizadeh R, Guicheux J, Couillaud S, Passuti N, Daculsi G, Heymann D: Osteogenic.Potential in vitro of human bone marrow cells cultured on macroporous biphasic

05. Maddox E, Zhan M, Mundy GR, Drohan WN, Burgess WH: Optimizing human demineralized bone matrixfor clinical application. Tissue Eng 6(4): 441-448, 2000 calcium phosphate ceramic. J Biomed Mater Res.1999 Jan; 44(1):98-108.

06. Gauthier O, Bouler JM, Aguado E, Pilet P, Daculsi G: Macroporous biphasic calcium phosphate ceramics:influence of macropore diameter and macroporosity percentage on bone ingrowth. Biomaterials 1998 JanFeb;19(1-3):133-9.

07. Martinetti R, Belpassi A, Nataloni A, Biasini V, Martignani G: Idrossiapatite porosa sintetica per sostituzioniossee: Caratterizzazione Chimico-Fisica. Biomateriali: Atti del Congresso; 51 55, Roma Enea, 1999

08. Martinetti R, Belpassi A et al.: Key Engineering Materials Vols. 192-195 (2001), 507-510 – Proceeding ofthe 13th Int. Symp. On Ceramics in Medicine, Bologna, Italy, 22-26 Nov.

09. Caplan AI: Mesenchymal stem cells. J Orthop Res 9: 641-650, 199

10. Nyman S, Lindhe J, Karring T et Rylander H: New attachment following surgical treatment of humanperiodontal disease. Journal of Clinical Periodontology 9: 290-296, 1982; 39

11. Hämmerle CH, Brägger U, Bürgin W, Lang NP: The effect of subcrestal placement of the polished surfaceof ITI implants on marginal soft and hard tissues. Clin Oral Implants Res. 1996 Jun;7(2):111-9

12. Chin M: Distraction Osteogenesis in Maxillofacial Surgery. In Lynch SE, Genco RJ, Marx RE (eds). TissueEngineering – Application in Maxillofacial Surgery and Periodontics. Illinois; Quintessence Publishing Co,Inc, 1999; 147

13. Arun K. Garg: Grafting Materials in Repair and Restoration. In Lynch SE, Genco RJ, Marx RE, (eds). TissueEngineering - Application in Maxillofacial Surgery and Periodontics. Illinois; Quintessence Publishing Co,Inc, 1999; 83

14. Scipioni A, Bruschi GB, Calesini G: The edentulous ridge expansion technique: A five-year study. Int JPeriodont Rest Dent 14: 451-459, 1994 Trans Tech Publications, Switzerland

15. Schenk RK and Buser D: Osseointegration: a reality. Periodontology 2000, Vol 17. 1998, 22.35

16. Bauer TW and Muschler GF: Bone graft materials. An overview of the basic science. Clin Orthop RelarRes, 2000 Feb;(371):10-27.


ß-tricalcium phosphate used withonlay graft for horizontal boneaugmentation yielded preferableresult: a case reportYaqian Chen, Qingqing Wu, Yi ManState Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, China

Rehabilitation of teeth lost due to disease,trauma, surgery or congenital problems withimplant-supported prosthesis has become acommon practice worldwide. (1) However, variousbone defects often exist in implant area. Insome severe atrophic cases, alveolar bone mustbe restored before or in combination with implantplacement. Bone augmentation using onlaybone grafts which are harvested from eitherintraoral or extraoral sites is currently one of themost reliable techniques with potential successrate. (2,3) However, the use of autografts onlyas onlay grafts has some drawbacks such asthe high morbidity at the donor site, limitedbone graft supply and the need for multiplesurgical sites. (4,5) Therefore, synthetic bonegraft materials have become a popular choicefor bone augmentation during last decade andthe application of different bone substitutes has

been described in different oral surgeries. (6.7.8.9) Recently, the synthetic bone graft based on ß-tricalcium phosphate which can be completelyabsorbed in 6 to 9 months has been reportedto be used in different oral surgeries such asalveolar preservation and periodontal defectswith satisfactory clinical and histologic results.(10.11.12) Tricalcium phosphate grafts has struc-tural characteristics which is similar to bonetissue, moreover, during reabsorption it canprovide ion calcium and magnesium for surroun-ding tissue, thus creating a correct ionicenvironment, which could activate more alkalinephosphatase for further bone synthesis. (13) The purpose of this case report is to presentclinical and radiographic results for a patienttreated with ß-TCP bone substitute with auto-genous bone block harvested in situ as onlaygrafts for horizontal bone augmentation.

Introduction

22


23

Case Report

Fig. 1: Pre-surgery oral examination showed acceptable verticalheight of the frontal bony shelf in anterior maxillary.

Fig. 2: Pre-surgery oral examination from occlusal view indicatedhorizontal bone defect.

Fig. 4: Vertical andcrestal incision wasmade to expose thelabial surface ofanterior alveolar bone.

Fig. 5: Two boneblocks outlined byultrasonic instrumentsfrom basal base apicalto the recipient site.Fig. 3: Presurgery CBCT examination showed width and height of

alveolar ridge before bone augmentation.

A 36 year-old healthy male with good oralhygiene required implant supported prosthesisfor his two maxillary central incisors and rightlateral incisor (tooth 11,12,21). (Fig1,2) Pre-surgery radiographic examination showedinsufficient bone volume for placement ofimplants 3.3 mm in diameter. (Fig.3) After administration of local anesthesia, crestaland vertical incisions were made to expose thelabial surface of the absorbed alveolar ridgeand two autogenous bone block was harvestedapical to the recipient site from the basal baseand ß-TCP bone graft (RTR Syringe package,Septodont, France) was placed in the donor

site and dressed on the autogenous block.(Fig.4-9) Then the incision was closed after atitanium mesh and a barrier membrane wascovered. (Fig.10) Routine anti-inflammatorytherapy and prophylactic antibiotics were pres-cribed.Six months later, a reentry surgery was performed.The bone graft material has been replaced bynew formed bone which is an inspiring result ascompared with six months ago. Two implantswere inserted at tooth 12 and 21with goodprimary stability. (Fig.11-13) CBCT examinationspresented favorable outcome of the horizontalbone augmentation. (Fig.14-15)


24

Fig. 6: Use the filter of the syringe package sucking blood insurgical area.

Fig. 7: Fix two blocks on the alveolar ridge with titanium screws.

Fig. 9: Finish dressing R.T.R. graft on the blocks.Fig. 8: Inject R.T.R. graft into the donor site.

Fig. 10: Flap closed with a releasingincision.

Fig. 12: Horizontal alveolar ridge wasaugmented by new formed bone.

Fig. 11: Occlusal view six months later.

Fig. 13: Two implants were placed in theanterior maxillary.

Fig. 14: CBCT of tooth 12 immediately after bone augmentation , six month later andimmediately after implantation.

Fig. 15: CBCT of tooth 21 immediately after bone augmentation , six month later andimmediately after implantation.


25

This case report showed the potential advantageof ß-tricalcium used with onlay graft for boneaugmentation. The clinical and radiographicresults show that this synthetic graft has beenreplaced by new formed bone six months later.Among all the graft materials, tricalcium phos-phate is of special interest because it is aresorbable and osteoconductive biomaterial. (15)The in vivo osteoconductivity of synthetic bonegraft is dependent on several properties includingsurface morphology, chemical composition andgeometry at both the macro- and micro-scale.The pore size and interconnectivity of biomaterialscan significantly influence the exchange of fluidsthrough grafts and the delivery of ions, nutrientswithin and through the bone substitute. (16,17,18)

The bone graft used in this case consists ofpure ß-tricalcium with an appropriate macro-and micro-scale which turn to be good osteo-conductivity and make this graft a potentialscaffold for osteoblasts. Moreover, pure ß-TCPcan be totally absorbed in 6 months thusleaving no residuals in the implant area whichmay influence the remodeling of bone regene-ration. (15)ß-TCP used with autogenous bone block asonlay graft for anterior bone augmentation inthis case gained inspiring result which is a moti-vation for more oral surgeons to conduct similarcases. Despite the favorable result of the primarysurgery, long term observation is still neededfor a series of clinical cases.

Discussion

Authors:Yi ManFrom 2007 up to date: Clinical Lecturer of Implant Center, West China Collegeof Stomatology, Sichuan University, China. From 2010.09 – 2012.07: Clinical instructor, Clinical Lecturer of Tufts UniversitySchool of Dental Medicine, Boston, USA. From 2011.6-2012.7: Research Scholar of Massachusetts General Hospital ofHarvard University, Massachusetts, USA. From 2012.6 up to date: Standing Committee Member of Special Committeeof Implant, Medical Society of Sichuan province, China. From 2012.7 up to date: Associate professor of Oral Implantology Department,West China School of Stomatology, Sichuan University, China. From 2012.9 up to date: Standing Committee Member of Committee ofImplantology, Medical Society of China. From 2013.2 up to date: Chair of Oral Implantology Department, Chair ofEducational and research section of Oral Implantology, West China School ofStomatology, Sichuan University, China. From 2014.11 up to date: International team for Implantology fellow.

Yaqian ChenResident of Department of Implantology, West China Hospital of Stomatology,Sichuan University, China.

Qingqing WuResident of Department of Implantology, West China Hospital of Stomatology,Sichuan University, China.


26

References01 Levin L. Dealing with dental implant failures. J Appl Oral Sci 2008;16:171-175.

02 Hill NM, Horne JG, Devane PA. Donor site morbidity in the iliac crest bone graft. Aust N Z J Surg1999;69:726-728.

03 Isaksson S, Alberius P. Maxillary alveolar ridge augmentation with onlay bonegrafts and immediateendosseous implants. J Cranio maxillofac Surg 1992;20:2-7.

04 Chiapasco M, Zaniboni M, Rimondini L. Autogenous onlay bone grafts vs. alveolar distraction osteogenesisfor the correction of vertically deficient edentulous ridges: a 2-4-year prospective study on humans. ClinOral Implants Res 2007;18:432-440.

05 Felice P, Marchetti C, Iezzi G, Piattelli A, Worthington H, Pellegrino G, et al. Vertical ridge augmentation ofthe atrophic posterior mandible with interpositional bloc grafts: bone from the iliac crest vs. bovine anorganic bone. Clinical and histological results up to one year after loading from a randomized-controlledclinical trial. Clin Oral Implants Res 2009;20: 1386-1393.

06 Wang M. Developing bioactive composite materials for tissue replacement. Biomaterials 2003; 24:2133-2151.

07 Schmitt CM, Doering H, Schmidt T, Lutz R, Neukam FW, Schlegel KA. Histological results after maxillarysinus augmentation with Straumann® BoneCeramic, Bio-Oss®, Puros®, and autologous bone. A randomizedcontrolled clinical trial. Clinical Oral Implants Research 2013; 24:576-585.

08 Klijn, R.J., Meijer, G.J., Bronkhorst, E.M. & Jansen, J.A. A meta-analysis of histomorphometric results andgraft healing time of various biomaterials compared to autologous bone used as sinus floor augmentationmaterial in humans. Tissue Engineering Part B: Reviews 2010; 16: 493–507.

09 Tamimi F, Torres J, Al-Abedalla K, Lopez-Cabarcos E, Alkhraisat MH., Bassett DC., Gbureck U, BarraletJE.. Osseointegration of dental implants in 3D-printed synthetic onlay grafts customized according to bonemetabolic activity in recipient site. Biomaterials 2014; 35:5436-5445.

11 Brkovic BM, Prasad HS, Rohrer MD, Konandreas G, Agrogiannis G, Antunovic D, Sándor GK. Beta-tricalcium phosphate/type I collagen cones with or without a barrier membrane in human extraction sockethealing: clinical, histologic, histomorphometric and immunohistochemical evaluation. Clin Oral Investig2012; 16: 581-590.

12 Stavropoulos A, Windisch P, Gera I, Capsius B, Sculean A, Wikesjö UM. A phase IIa randomized controlledclinical and histological pilot study evaluating rhGDF-5/ß-TCP for periodontal regeneration. Journal ofClinical Periodontology. 2011; 11:1044-1054.

13 Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting with beta-tricalcium phosphate in humans: density and microarchitecture of the newly formed bone. Clin OralImplants Res. 2006; 17:102-108.

14 Hirota M, Matsui Y, Mizuki N, Kishi T. Combination with allogenic bone reduces early absorption of beta-tricalcium phosphate (beta-TCP) and enhances the role as a bone regeneration scaffold. Experimentalanimal study in rat mandibular bone defects. Dent. Mater. J. 2009; 28: 153.

15 Rodella LF, Favero G, Labanca M. Biomaterials in Maxillofacial Surgery: Membranes and Grafts.International journal of Biomedical science 2011; 7: 81-88.

16 Gendler E. Perforated demineralized bone matrix: a new form of osteoinductive biomaterial. J BiomedMater Res 1986;20:687-697.

17 Habibovic P, Yuan H, van der Valk CM, Meijer G, van Blitterswijk CA, de Groot K. 3D microenvironment asessential element for osteoinduction by biomaterials. Biomaterials 2005;26:3565-3575.

18 Walsh WR, Vizesi F, Michael D, Auld J, Langdown A, Oliver R, et al. ß-TCP bone graft substitutes in abilateral rabbit tibial defect model. Biomaterials 2008;29:266-271.


27

The dimensions of the alveolar ridge may beseriously affected following dental extraction asa result of normal alveolar bone remodelling.1, 2

Although the bone loss occurs in both the hori-zontal and vertical aspects, greater bone loss isobserved in the horizontal dimension.3

Schropp et al.1 found that the greatest loss ofalveolar height occurred during the first 3 monthsand less than 50% of the width of the ridge waslost after 1 year. Other studies observed lossesamounting to 40% of height and 60% of widthafter only 6 months.3,4

During the 80's and in the early 90's, bonegrafting procedures were commonly performedusing autogenous bone or fresh frozen allografts,but the advent of efficient and safe processingand the sterilisation techniques led to an increa-sing use of bone graft substitutes for theprocedures of periodontal regeneration and

alveolar ridge augmentation.7, 8

The main advantages in using bone graftingsubstitutes are their unlimited availability andthe reduction in the morbidity associated withthe harvest of autologous bone at a secondintraoral or extraoral surgical site.9

The development of synthetic or combinedbiological-synthetic alloplastic materials for boneregeneration has become more widespreadduring recent years. This type of material mayintegrate or resorb completely, forming lamellarbone at the site. Inorganic ceramics based oncalcium phosphate (α-tricalcium phosphate, ß-tricalcium phosphate and hydroxyapatite)contrast with bone regeneration materials ofbiological origin in the sense that the syntheticmaterials have their physical and crystallographiccharacteristics clearly defined in addition to thechemical properties (chemical composition andpurity).11

Bone regeneration with ß-tricalcium phosphate (R.T.R.) in post-extraction socketsProf. Oscar Hernán Arribasplata LoconiDepartment of Odontology, Norbert Wiener University, Lima, Peru

Two clinical cases are presented in which ß-tricalcium phosphate "R.T.R." (Septodont)was used for post-extraction bone regeneration to preserve the alveolar ridge in heightand width for future dental implants placement. Resorption of the filling material isdemonstrated by a histological study as well as good clinical and tomographic results.

Introduction


28

ß-tricalcium phosphate has been used in variousstudies in animals and in humans in order todemonstrate its efficiency as a bone regenerationbiomaterial.

AimsHistological, tomographic and clinical evaluationof alveolar ridge preservation in width and heightfollowing the insertion of ß-tricalcium phosphate“R.T.R”. (Septodont) in post-extraction socketsfor future dental implants placement.

Materials & MethodsIn order to be able to observe whether thealloplastic filling material, ß-tricalcium phosphate“R.T.R.” (Septodont) resorbs completely, ahistological study was performed 12 monthsafter grafting the material in the alveolar socket,the biopsy being done at the time of implantplacement.This material was used in cone presentationwhen the post-extraction socket was wellpreserved by atraumatic extractions. Howeverthe material was used in syringe presentationcombined with resorbable membranes in bonedefects in which the vestibular bone plates werelost. Absorbable polyglycolic acid sutures of 4/0zeroes with a sharp needle 3/8 circle were used.The grafted sockets were observed radiogra-phically after 6 and 12 months.

ResultsThe material’s ability to resorb and form new boneyielded excellent results, demonstrated by a histo-logical study done 12 months after placement,as well as by a case of bone regeneration usinga membrane (imminent vestibular destruction),for which a control tomography was performedafter 18 months showing excellent results.

The results obtained in this study confirm themain observations of other clinical and experi-mental studies performed any other groups ofprofessionals.

Case Report no.1A 29-year-old woman came with a fistula atthe level of tooth 2.5; grade II tooth mobility.On X-ray examination, a radiopaque imagewas observed in the canal showing a post andcore restoration; periapically, a radiolucentlesion was observed, potentially revealing aninfectious process.

Fig. 1: Presence of the fistula at tooth 2.5.

Fig. 2: Fistulography (cone no. 25).

Fig. 3: Panoramic X-ray.


29

Fig. 4: Atraumatic extraction.

Fig. 7: a) Partial thickness flap, b) Placement of the ß-tricalcium phosphate (R.T.R.) in the alveolar socket, c) Suturing of the flapwith Vicryl 5/0 zeroes figure-of-eight sutures.

Fig. 5: Extracted tooth. Fig. 6: ß-tricalcium phosphate (R.T.R.).

A B C

Fig. 8: Clinical examination (12 months).

Fig. 9: Periapical X-ray (12 months).

The tooth was extracted and the ß-tricalciumphosphate filling material "R.T.R" (Septodont)was placed, without a membrane; a partial thick-ness flap was raised in order to cover the graftand the wound was sutured using 4/0 polyglycolicacid sutures with a sharp needle 3/8 circle. She was prescribed: Amoxicillin 500 ml/clavulanicacid 125 mg once every 8 hours x 5 days.Ibuprofen 400 mg once every 8 hours for 3 days.Soft diet x 48 hours.The sutures were removed after 2 weeks. She was advised to get X-ray controls after 3, 6and 12 months. After 12 months, the patientreturned for consultation; she had been unableto do so before for reasons beyond her control.A clinical examination was performed (Fig. 8) inaddition to a periapical X-ray with a metal mesh(grip). On the periapical X-ray done after12 months a circumscribed radiopaque image,round in shape, was observed in the area of thegraft as if it were apparently an encapsulationof the material (Fig. 9).


30

After 12 months, it could be clinically observedhow the alveolar ridge had been maintainedboth in width and height and in order to verifywhether the ß-tricalcium phosphate (R.T.R.) hadresorbed completely, we took a sample fromthe area to be implanted and performed a histo-logical study (Fig. 10).

The treatment plan was thoroughly implementedfor a correct insertion and placement of thedental implant. We knew that computerisedaxial tomography would provide a more precisediagnosis with respect to bone width and height.However since a single dental implant wasinvolved and moreover a fairly well preservedridge was clinically observed, we used theclinical mapping method. Doing our measurements, we had a palatinevestibular width of 8 mm and a width of 7 mmmesiodistally. The calculation of the height usingthe periapical X-ray done with metallic mesh(grip) and a parallel method gave us an approxi-mation of the actual height, which was 10 mm.After obtaining all the measurements of8x7x10mm, it was decided to perform maxillarysinus lift using Summer's technique.

Dental implant placementUsing a trephine drill 2 mm in diameter, weremoved bone tissue from the alveolar ridge forits histological study in which we wanted tofind out whether the ß-tricalcium phosphate(R.T.R.) had resorbed completely. The samplewas placed in 10% formocresol.Then we positioned our surgical guide in orderto perform the sequential drilling for implantplacement, using helical drills; a control X-ray

of the preparation was taken, inserting a paral-leling pin in the alveolar socket (Fig. 12b), whichshowed us correct parallelism with the prepa-ration; it was observed how the paralleling pinremained exactly 2 mm away from the sinusfloor (Fig. 12c), since it was taken with a grip;then Summer's technique was performedapproach to the Schneider membrane usingosteotomes, from crestal bone leaving 1-2 mmof residual bone before the floor of the maxillarysinus13. This dimension of bone was increased by meansof pressure, pushing the membrane upwards

Fig. 10: a) Tissue sample, removed using a 2mm trephine drill, in thearea in which the dental implant is to be inserted. b,c) Histologicalresults after 12 months. Haematoxylin eosin tincture under lightmicroscopy. New bone formation at the level of the ß-tricalciumphosphate absorption site.

Fig. 11: Clinical mapping. a) Placement of the saddle-shaped acrylic on the area for taking of measurements, tooth 2.5. b) Taking ofmeasurements (file no. 25). c) Transfer of measurements to the trimmed model.

A B C

A

C

B


31

without perforating the latter and creating thespace required to place biomaterials or theimplant. Once the sinus floor elevation was achieved,which could allow a gain between 3 and 4 mmin height 13-15, the implant, Conexão of11.5 x 4 mm cylindrical internal hexagon, wasinserted; in this case we succeeded in elevatingthe sinus floor by 3.5 mm. (Fig.13)Finally, a partial thickness flap was performedwith 2 liberating incisions in order to be able toconfront the soft tissues in the palatine direction;figure-of-eight sutures and X (cross) sutureswere inserted in order to protect the tissue andavoid collapse; the liberating incisions were

sutured with circumferential sutures. Vicryl 5/0zeroes was used for synthesis (Fig. 14 a). Thepostoperative X-ray was performed confirmingthe elevation of the sinus floor by approx.3.5 mm. (Fig. 14b)She was prescribed: Amoxicillin 500 ml/clavu-lanic acid 125 mg once every 8 hours x 5 days.Ibuprofen 400 mg once every 8 hours for 3 days.Soft diet x 48 hours.The sutures were removed after 2 weeks. Thepatient was advised to wait for 6 months forosseointegration. The results of the histologicalstudy showed bone neoformation with absenceof ß-tricalcium phosphate (R.T.R.) filling material.

Fig. 12: Preparation for implant placement. a) Paracrestal incision and raising of the flap. b) Insertion of the paralleling pin. c) X-ray showing2 mm before reaching the maxillary sinus.

Fig. 13: Maxillary sinus lift with osteotomes (Summer's technique) and placement of the 11.5 x 4 cylindrical, internal connection Conexãoimplant.

A B C


32

Fig. 15: Open-tray impression taking, application of transfer and analog on the impression.

Fig. 16: Prepared abutment and application of the porcelain crown.

Fig. 14: Full thickness flap and suture with Vicryl 5/0 zeroes. g) Postoperative X-ray showing the 3.5 mm maxillary sinus lift achieved usingSummer's technique.

Implant activation


33

Case Report no.2A 54-year-old woman came with grade III toothmobility at tooth 1.1. On X-ray examination, aradiopaque image was observed in the canalshowing a post and core restoration. The patientpresented with an obvious root fracture onclinical examination.Atraumatic extraction of the tooth was performed,then the guided bone regeneration procedurewith ß-tricalcium phosphate (R.T.R. - Septodont)

was done, in addition to the use of a resorbablemembrane. A partial thickness flap wasperformed in order to cover the graft and themembrane, the wound was sutured using 4/0polyglycolic acid sutures with a sharp needle3/8 circle. The sutures were removed after2 weeks. She was recommended to get X-raycontrols after 3, 6 and 12 months.

Fig. 1: Initial photo. Tooth 1.1 with extrusion and grade III mobility. Fig. 2: Initial X-ray. a) Tooth 1.1, presence of an excessively widepost and core, the probable cause of root fracture. b) X-ray with grip.

Fig. 5: R.T.R. in cone presentation.Fig. 4: Extraction of tooth 1.1, loss of thevestibular bone plate due to the fracturewhich remained for a long period in themouth.

Fig. 3: The major root fracture can beconfirmed when raising the full thicknessflap.

Fig. 8: Modelling of the R.T.R. cone.Fig. 7: Placement of the R.T.R. cone.Fig. 6: Major vestibular bone loss.


34

Conclusion• ß-tricalcium phosphate (R.T.R.) has proven to

be a good osteoconductive material for boneregeneration following the filling of a post-extraction socket, allowing the preservationof the alveolar ridge in order to place a dentalimplant.

• Its ability to resorb and form new bone yieldedexcellent results, demonstrated by a histolo-gical study done 12 months after placement,as well as by a case of bone regeneration

using a membrane, since vestibular destructionwas imminent, where a control tomographywas performed after 18 months showingexcellent results.

• It is easy to use and handle.• The results obtained in this project confirm

the main observations of other clinical andexperimental studies performed any othergroups of professionals.

Fig. 11: Interrupted figure-of-eight sutures.Palatine view.

Fig. 10: Interrupted figure-of-eight sutures.A partial thickness flap was performed tocover the membrane.

Fig. 9: Insertion of a collagen membranedue to an important vestibular bone loss.

Fig. 13: Final X-ray.Fig. 12: Ridge preservation in width and height. The appearance of recessions at the level ofteeth 1.2 - 2.2 had been explained to the patient before surgery.

Fig. 15: Bone regeneration in the areacorresponding to tooth 1.1 was visible.

Fig. 14: Tomography 18 months after surgery in order to check bone regeneration beforeinserting a dental implant.


35

References

01. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes followingsingle-tooth extraction: A clinical and radiographic 12-month prospective study. Int J PeriodonticsRestorative Dent 2003;23:313-323.

02. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal wall of extraction sockets of teethwith prominent roots. Int J Periodontics Restorative Dent 2006;26:19-29.

03. Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets usingbioabsorbable membranes. J Periodonto.l 1998; 69: 1044-1049.

04. Iasella JM, Greenwell H, Miller RL, et al. Ridge preservation with freeze-dried bone allograft and a collagemembrane compared to extraction alone for implant site development: A clinical and histologic study inhumans. J Periodontol 2003;74:990-999.

05. Schallhorn RG, Hiatt WH, Boyce W. Iliac transplants in periodontal therapy. J Periodontol 1970;41:566-580.

06. Tonetti MS, Hammerle CH. Advances in bone augmentation to enable dental implant placement: ConsensusReport of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008;35:168-172.

07. Cortellini P, Bowers GM. Periodontal regeneration of intrabony defects: an evidence-based treatmentapproach. Int J Periodontics Restorative Dent 1995;15:128-145.

08. Mellonig JT, Bowers GM, Bright RW, Lawrence JJ. Clinical evaluation of freeze-dried bone allografts inperiodontal osseous defects. J Periodontol 1976;47:125-131.

09. Rawashdeh MA, Telfah H. Secondary alveolar bone grafting: the dilemma of donor site selection andmorbidity. Br J Oral Maxillofac Surg 2008;46:665-670.

10. Gustavo Avila-Ortiz; Satheesh Elangovan; Nadeem Karimbux. Bone Graft Substitutes for PeriodontalUse Available in the United States. Clinical Advances in Periodontics; Copyright 2012. DOI: 10.1902/cap.2012.120043.

11. Horch HH, Sader R, Pautke C, Neff A, Deppe H, Kolk A. Synthetic, pure-phase ß-tricalcium phosphateceramic granules (Cerasorb) for bone regeneration in the reconstructive surgery of the jaws. Int J OralMaxillofac Surg. 2006;35(8):708-13.

Author: Prof. Oscar Hernán Arribasplata LoconiStudied Dentistry at the University Inca Garcilaso de la Vega. (Peru-2001).Second Specialization in Periodontics and Implants at the University National ofSan Marcos (Peru-2010).Master of Dentistry at the University Inca Garcilaso de la Vega (Peru-2011).Certified in Orthodontics at the Dental Association of Peru ( Lima-2005).Certified in Teaching Strategies and competency assessment at the University

Norbert Wiener (Peru-2012).Post-Graduate Course in Forensic Dentistry at the University National of San Marcos (Peru-2011).Post-Graduate Course in Auditing and Forensic Dentistry at the University Peruana CayetanoHeredia (Peru-2012).Professor of Periodontology II, Theory and Practice at the University Norbert Wiener (Lima;2010-2013).Professor invited to the second specialty in Oral Rehabilitation at the University National of SanMarcos (2012).Ex-Professor of Periodontal Surgery at the University National of San Marcos (2010). Publication of articles in the specialty of Periodontics. Member of the Peruvian Association of Periodontology and Osseointegration. Lecturer at National and International Conferences.


Use of R.T.R. and PRF as fillingmaterial in post extraction socketsDr. Patricio González, Dr. Omar González, Dr. Claudia Zenteno, Dr. Joaquín UrrizolaSan Sebastian University, Concepción, Chile

Currently, the great majority of the extractionsare followed by the immediate use of an implant.In some cases the bone volume is not enoughto get the desired primary stability, in that casethe clinician will need a first surgery where hewould win the bone volume required for thatimplant, and then a second surgery for the finalplacement of the implant1.To obtain the best results possible, the use of amaterial that guides the bone regeneration isnecessary and ß-tricalcium phosphate has provena great efficacy in helping and maintaining thespace for the bone regeneration2. In addition to

this, the use of platelet rich fibrin (PRF), a secondgeneration platelet concentrate, that acts as abioscaffold and has multiple growth factors, canaccelerate the process of regeneration3. The characteristics of R.T.R. are its porosity,that helps in the formation of stronger clots, nosystemic toxicity and its resorbability thatpromotes new bone formation in 3 - 6 months.In synergy with this, PRF thanks to its growthfactors promotes the new bone formation and,as an optimized clot, helps to get a faster rege-neration of the extraction socket and to have amore predictable outcome4, 5.

Introduction

A 59 year-old woman, systemically healthy andunder periodontal treatment, requires the extractionof the left central incisor (2.1) and left lateralincisor (2.2) to be rehabilitated with osseointegratedimplants in a second surgery after the alveolarpreservation surgery. The lateral incisor presentsa radiolucent lesion around the root and nopresence of vestibular wall in 2.1. The surgery

was explained to the patient with the risks andbenefits and an informed consent was signed.Local anesthesia was administered to the patient.The teeth were extracted with a forceps takingcare to preserve the alveolar walls. After theextraction, a full mucoperiostal flap was elevatedwhich allowed to confirm the great loss ofalveolar bone.

Case report

36


37

Two blood tubes of 9 ml without anticoagulantwere obtained from the patient’s ante cubitalvein for the production of the PRF. The PRFwas produced following Choukroun protocol(3000 rpm by 10 min)6, 7 and then compressedinto two membranes8, 9. The exudate of thecompression was collected with a syringe tobe applied over the bone graft. One of themwas cut and mixed with R.T.R. fragments to beused as the bone graft and the other one was

used as a membrane6, 7. R.T.R. was fragmented to get a better adaptationto the defects, and once mixed with the PRFmembrane, it was placed in the defects. Whenthe graft was ready the exudate was thenapplied to it. When suturing, the membranewas applied with a pocket technique to ensureits intimate contact with the bone graft10. Theflap was closed with simple stitches and infirst intention.

Fig. 1: Extraction of 2.1 Fig. 2: Extraction of 2.2

Fig. 4: The extracted dental pieces Fig. 5: Mucoperiosteal flap elevation

Fig. 3: The two alveolar sockets

Fig. 6: R.T.R. cone Fig. 7: PRF clot Fig. 8: PRF clot before mixing with the graft

Fig. 9: PRF membrane mixed with the graft Fig. 10: Application of the graft Fig. 11: Graft placed


38

The use of platelet concentrates has becomepopular during the last 10 years, but amongthem, one of the simplest and cheapest formhas raised as one of the best options, the PRF.As a cheap and free access platelet concentrate,its homogenous bibliography supports its goodresults as an adjuvant in multiple surgeries likesinus lifts, intrabony defect fillings and of coursebone grafting6, 7. Although PRF acts as a bios-caffold, it lacks a good resistance and resorbsin around 28 days, thus the use of a materialthat sustains bone regeneration is necessary,and that material is R.T.R.

Beta-Tricalcium Phosphate has a proven biocom-patibility, osteoconductivity and resorbability.As it resorbs, R.T.R. releases calcium and phos-phate ions which help in the neo formation ofthe bone11.The combination of two materials with notknown local or systemic toxicity and that syner-gize in the formation of bone should reduce thetime needed to place the implants. The bonegraft that best suits the PRF characteristics stillneeds further and deep study, but R.T.R. seemsto perfectly fit all the characteristics to maximizethe bone regeneration.

Discussion

Fig. 12: Application of the exudate Fig. 13: Suture Fig. 14: PRF membrane

Fig. 15: Immediate post-operative situation Fig. 16: X-ray pre-operative Fig. 17: X-ray 1 week post-operative


39

References1. Ten Heggeler, J. M. a G., Slot, D. E. & Van der Weijden, G. a. Effect of socket preservation therapies following

tooth extraction in non-molar regions in humans: a systematic review. Clin. Oral Implants Res. 22, 779–88(2011).

2. Geurs, N. et al. Using growth factors in human extraction sockets: a histologic and histomorphometricevaluation of short-term healing. Int. J. Oral Maxillofac. Implants 29, 485–96 (2014).

3. Kang, Y.-H. et al. Platelet-rich fibrin is a Bioscaffold and reservoir of growth factors for tissue regeneration.Tissue Eng. Part A 17, 349–59 (2011).

4. Dohan Ehrenfest, D. M., Del Corso, M., Diss, A., Mouhyi, J. & Charrier, J.-B. Three-dimensional architectureand cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. J. Periodontol. 81, 546–55(2010).

5. Choukroun, J. et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinicaleffects on tissue healing. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 101, e56–60 (2006).

6. Del Corso, M. et al. Current Knowledge and Perspectives for the Use of Platelet-Rich Plasma (PRP) andPlatelet-Rich Fibrin (PRF) in Oral and Maxillofacial Surgery Part 1: Periodontal and Dentoalveolar Surgery.Curr. Pharm. Biotechnol. 13, 1207–1230 (2012).

7. Simonpieri, A. et al. Current Knowledge and Perspectives for the Use of Platelet-Rich Plasma (PRP) andPlatelet-Rich Fibrin (PRF) in Oral and Maxillofacial Surgery Part 2 : Bone Graft , Implant and ReconstructiveSurgery. 1231–1256 (2012).

8. Dohan Ehrenfest, D. M. How to optimize the preparation of leukocyte- and platelet-rich fibrin (L-PRF,Choukroun’s technique) clots and membranes: introducing the PRF Box. Oral Surg. Oral Med. Oral Pathol.Oral Radiol. Endod. 110, 275–8; author reply 278–80 (2010).

9. Kobayashi, M. et al. A proposed protocol for the standardized preparation of PRF membranes for clinicaluse. Biologicals 40, 323–9 (2012).

10. Dohan Ehrenfest, D. M., Doglioli, P., de Peppo, G. M., Del Corso, M. & Charrier, J.-B. Choukroun’s platelet-rich fibrin (PRF) stimulates in vitro proliferation and differentiation of human oral bone mesenchymal stemcell in a dose-dependent way. Arch. Oral Biol. 55, 185–94 (2010).

11. Observations, H., Brkovic, B. M. B. & Prasad, H. S. Pratique Simple Preservation of a Maxillary ExtractionSocket Using Beta-tricalcium Phosphate with Type I Collagen : Preliminary Clinical and. 74, 523–528 (2008).

Authors

Dr. Patricio González Catalán: Oral Surgeon, University of Concepción, Chile.Specialist of Periodontics and Implantology, University of Chile.Specialist of Oral Pathology, University of Concepción, Chile.Resident in department of Maxillofacial Surgery, St Sebastian University, Chile.Ex-docent of Periodontics Chair, University for Development, Concepción, Chile.National and international speaker.

Dr. Omar González: Oral Surgeon, University of Concepción, Chile.Docent, Chair of Anatomy, St Sebastian University, Concepción, Chile.Resident in department of Oral Rehabilitation, St Sebastian University,Concepción, Chile.

Dr. Claudia Zenteno: Specialist of Oral Rehabilitation.Master in Education in Catholic University of the Most Holy Conception, Chile.Docent coordinator of adult clinic and pre-clinic in San Sebastián University,Concepción, Chile.Secretary and active member of the Society for Oral Rehabilitation, University ofConception, Chile.

Dr. Joaquín Urrizola: Degree in Dentistry, St Sebastian University, Concepción,Chile. Pending certification.


40

Alveolar Ridge PreservationWith Alloplastic MaterialAna I. Coello GómezDentist, Master Oral Surgery, University of Seville, SpainSelene P. Navarro SuárezDentist, Master Oral Surgery, University of Seville, SpainDaniel Torres LagaresCo-director of the Master in Oral Surgery, University of Seville, SpainJose Luis Gutiérrez PerezCo-director of the Master in Oral Surgery, University of Seville, Spain

Alveolar ridge preservation is done when it isexpected that following a tooth extraction thispart will be rehabilitated by an implant to minimizethe bone resorption that occurs during the biolo-gical healing of the socket. Current studiesallow us to expect that, with the alveolar ridgepreservation technique, we will decrease thevolume loss by around 1 mm in height and3 mm in width.1

Different techniques and materials have beenused in recent years, all based on three biologicalmechanisms that promote alveolar healing: 2-4- Osteogenesis: formation of new bone from

viable and precursor osteoblasts, transplantedwith graft material.

- Osteoinduction: formation of new bone by

differentiation of local connective tissue cellsin bone-forming cells, under the influence ofone or more inductors.

- Osteoconduction: formation of new bone bythe network generated by a non-vital graftmaterial, which allows the penetration ofprecursor osteoblasts present in the defect.

The various types of grafts can be classifiedaccording to their origin in: autografts, allografts,xenografts, and alloplastic materials.- Autografts: bone grafts that come from a

donor area of the same individual. They areosteogenic, but have high resorption.

- Allografts: bone grafts from a member of thesame species. They can be mineralized. Inprinciple, they are associated with osteoin-ductive and osteoconductive properties.

Introduction and objective


41

- Xenografts: bone grafts from other specieswith osteoconductive properties.

- Alloplastic materials: bone grafts of syntheticorigin (hydroxyapatite, bioactive glass, tricalciumphosphate, etc). They have osteoconductiveproperties.

Among the various available techniques described,the objective of this article is to present a casereport of preservation with an alloplastic materialwithout the need for membrane.

Case ReportA female patient, 53 years of age, with nospecial medical history, presented for alveolarridge preservation of tooth 47 for subsequentrehabilitation with implant. The patient had anendodontically-treated, infected and fracturedtooth (Fig. 1-3). The chosen treatment was itsextraction and, given the risk of placing animplant in such conditions, we decided to post-pone it, preserving the alveolar ridge.

After the careful extraction of the tooth and withoutraising a flap (Fig. 4), we proceeded to a thoroughcurettage, irrigating the socket using 0.2% chlo-rhexidine. Once the socket was disinfected, wechecked that the walls were intact and proceededto fill it with the selected biomaterial.

In this case, we used a sterile resorbable beta-tricalcium phosphate material from Septodont(R.T.R.), presented in the form of 0.3 cm³ cones,made of beta tricalcium phosphate granulescoated with a matrix of highly purified collagenfibers of bovine origin which, in the case ofcavities that cannot be closed, prevents thegranules from leaking out.

The cone was placed in the socket using clamps(Fig. 5, 6), waiting for it to be carefully impregnatedwith the patient's own blood and compacting it(Fig. 7, 8). Finally, three crossed sutures weredone on top, leaving the material slightly exposed

Fig. 1: Preoperative intraoral view of the 1st and 4th quadrants.

Fig. 4: Preoperativeperiapical X-ray.

Fig. 2: Preoperative occlusalview of the lower arch.

Fig. 3: Panoramic X-rayshowing tooth 47, posteriorthree-unit porcelain-metaldental bridge, fractured,endodontically treated tooth,and apical radiolucent image.

Fig. 5: Image of the socketafter extraction, where weobserve the integrity of its walls.

Fig. 6: Image of the placementof the selected biomaterial,easy handling using clamps.

Fig. 7: Image that shows thefilling of the socket with thebiomaterial.

Fig. 8: Image where it is seenhow the cone is impregnatedwith the blood from the socket.


42

The case presented in this article correlates withprevious studies in which, by using ß-tricalciumphosphate and collagen bone grafts, it waspossible to largely maintain the dimensions ofthe alveolar ridge.

In oral implantology, the goal of bone regenerationtechniques is to increase or maintain bonevolume for implant placement. Bone regenerationcan be modified, by systemic factors, and also

by using biomaterials or bone substitutes. Tradi-tionally, the ideal material, considered as "goldstandard" for bone regeneration has been theautologous bone, taken from the patient. However,in recent decades, new human, animal or syntheticmaterials have been introduced, such as beta-tricalcium phosphate (R.T.R.), which has beenvery successful in implantological surgical tech-niques in experimental studies. 5-14Cardaropoli et al.15 and other studies16-18

Discussion

Fig. 9: Image finishing compacting the biomaterial. Fig. 10: Immediate postoperative image where the socket suturingis visible.

Fig. 11: Immediate postoperative periapical X-ray. Fig. 12: One-week periapical X-ray.

and checking the final status by X-ray (Fig. 9, 10).As post-op instructions, the patient wasinstructed to rinse with 0.2% chlorhexidinemouthwash, three times a day, from the secondday, and as medical treatment, amoxicillin 1 g1 tab/8hr/7days and ibuprofen 600 mg1 tab/8 hr/7 days were prescribed.

After one week (Fig. 11), we removed the suturesand observed the start of healing of the softtissues, also anticipating some maintenance ofthe alveolar ridge architecture, with less resorptionthan would occur spontaneously after simpleremoval of the molar.


43

showed that sites where preservation hadpreviously been done presented less resorptionat six months compared with areas withoutpreservation. However, even having performedan alveolar ridge preservation, the crestal resorp-tion in width was 17% to 25%.

On the other hand, it has also been studied thatthere is a little loss of crest height and widthafter preservation19, but even so, Lasella etal.20 concluded that the dimensions wereimproved, achieving conditions favorable forsubsequent implant placement.

The alloplastic material used in this case ispresented in the form of granules of beta trical-cium phosphate forming an osteoconductivemicro- and macro-porous structure that encou-rages a dense growth of new bone.

The degree of bone regeneration from tricalciumphosphate varies depending on its formulation,porosity, and the size of the particles. The beta

phase is more recommended because it is lesssoluble than the alpha phase.The dissolution rate of the material is related toits porosity, meaning that a greater porosityfavors its resorption. In addition, the porosity isessential for perfusion, since the blood vesselsand neoformed bone tissue need pores of atleast 60 microns to grow. The size of the particlesis also important since it has been shown that asmaller size causes less inflammatory reactionto a foreign body, which allows a stable mecha-nical interconnection and prevents phagocyticdisintegration 21.

From a clinical viewpoint, the various studiesthat use ß-tricalcium phosphate in oral implan-tology show that about six months can beconsidered as a bone healing period. 22-31The case reports in the literature show somesuccessful results and provide clinical evidenceto consider for future randomized and controlledclinical trials that more broadly study the benefitsof this technique.

Alveolar ridge preservation is a technique thathas shown to significantly reduce the boneresorption observed in the alveolar crest aftertooth extraction, helping in the formation ofhard tissue that is necessary for correct subse-quent implant placement.

ß-tricalcium phosphate (R.T.R.) has shown tobe a good osteoconductive material for boneregeneration after filling a post-extraction socket,

maintaining an adequate alveolar ridge for subse-quent placement of a dental implant.

When ß-tricalcium phosphate is gradually resorbed,it is replaced by bone similar to the originalbone, obtaining a regenerated vital bone tissue.The cone presentation, in addition to adaptingto the shape of the socket, does not need to becovered with a membrane, thus facilitating itsplacement and handling.

Conclusion


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References01 Orgeas et al. Surgical Techniques for Alveolar Socket Preservation: A systematic Review. Int. J. Oral

Maxillofac. Implants. 2013; 28: 1049-1061.02 Barone A, Nicoli N, Fini M, Giardino R, Calvo JL, Covani U. Xenograft versus extraction alone for ridge

preservation after tooth removal: a clinical and histomorphometric study. J Periodontol 2008; 79: 1370-1377.

03 Mardas N, Chadha V, Donos N. Alveolar ridge preservation with guided bone regeneration and a syntheticbone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial. Clin. Oral Impl. Res.21, 2010; 688–698.

04 Araujo M, Linder E, Wennström J, Lindhe J. The influence of Bio-Oss collagen on healing of an extractionsocket: an experimental study in the dog. Int J Periodontics Restorative Dent. 2008; 28: 123-135.

05 Sixto García lInares, Óscar Hernán Arribaspiata Loconi. Caso clínico: Utilización del fosfato tricálcico beta(R.T.R) para relleno alveolar post-exodoncia, para la posterior colocación de un implante dental.

06 Barone A, Nicoli N, Fini M, Giardino R, Calvo JL, Covani U. “Xenograft versus extraction alone for ridgepreservation after tooth removal: a clinical and histomorphometric study.” J Periodontol 2008; 79: 1370-1377.

07 Jensen SS, Aaboe M, Pinholt EM, Hjorting-Hansen E, Melsen F, Ruyter IE. Tissue reaction and materialcharacteristics of four bone substitutes. Int J Oral Maxillofac Implants 1996; 11: 55-66.

08 Norton MR, Wilson J. Dental implants placed in extraction sites implanted with bioactive glass: humanhistology and clinical outcome. Int J Oral Maxillofac Implants 2002; 17: 249-57.

09 Ormianer Z, Palti A, Shifman A. Survival of immediately loaded dental implants in deficient alveolar bonesites augmented with beta-tricalcium phosphate. Implant Dent 2006; 15: 395-403.

Authors:Ana Coello Gómez (Main author) Dentist, University of Seville.Master Oral Surgery, University of Seville.Assistant Professor of the Master of Oral Surgery, University of Seville.Member of the Spanish Society of Oral Surgery (SECIB)Private practice limited to oral surgery.

Selene P. Navarro SuárezDentist, University of Seville.Master Oral Surgery, University of Seville.Assistant Professor of the Master of Oral Surgery, University of Seville.Member of the Spanish Society of Oral Surgery (SECIB)Private practice limited to oral surgery.

Daniel Torres Lagares Dentist, University of Seville.Master Oral Surgery, University of Seville.Full Professor of the Master of Oral Surgery, University of Seville.Member of the Spanish Society of Oral Surgery (SECIB).

José Luis Gutiérrez Pérez Dentist and Oral and Maxillofacial Surgeon, University of Seville.Master Oral Surgery, University of Seville.Full Professor of the Master of Oral Surgery, University of Seville.Member of the Spanish Society of Oral Surgery (SECIB).


45

References10 Ogose A, Hotta T, Kawashima H, Kondo N, Gu W, Kamura T, Endo N. Comparison of hydroxyapatite and

beta tricalcium phosphates as bone substitutes after excision of bone tumors. J Biomed Mater Res 2005;72B: 94-101.

11 Linovitz RJ, Peppers TA. Use of an advanced formulation of beta-tricalcium phosphate as a bone extenderin interbody lumbar fusion. Orthopedics 2002; 25 (suppl): 585-589.

12 Franch J, Diaz-Bertrana C, Lafuente P, Fontecha P, Durall I. Beta-tricalcium phosphate as a synteheticcancellous bone graft in veterinary orthopaedics. Vet Comp Orthop Traumatol 2006; 4: 1-9.

13 Jensen SS, Broggini N, Horting-hansen E, Schenk R, Buser D. Bone healing and graft resorption ofautograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometric studyin the mandibles of minipigs. Clin Oral Impl Res 2006; 17: 237-43.

14 Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting withbetatricalcium phosphate in humans: desnity and microarchitecture of the newly formed bone. Clin OralImpl Res 2006; 17: 102-108.

15 Cardaropoli D, Cardaropoli G. Preservation of the postextraction alveolar ridge: a clinical and histologicstudy. Int J Periodontics Restestorative Dent 2008; 28: 469-477.

16 Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenancefollowing tooth extraction. Report of 10 cases. J Periodontol 1997; 68: 563–570.

17 Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets usingbioabsorbable membranes. J Periodontol 1998; 69: 1044-1049.

18 Ellingsen JE, Thomsen P, Lyngstadaas P. Advances in dental implant materials and tissue regeneration.Periodontology 2000 2006; 41: 136-56.

19 Vance G, Greenwell H, Miller R, Hill M, Johnston H, Scheetz J. Comparison of an allograft in an experimentalputty carrier and a bovine-derived xenograft used in ridge preservation: a clinical and histologic study inhumans. Int J Oral Maxillofac Impl 2004; 19: 491–497.

20 Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA, Scheetz JP. Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development:a clinical and histologic study in humans. J Periodontol 2003; 74: 990-999.

21 Jensen OT, Garlini G, Bilk D, Peters F. Use of alloplasts for sinus floor grafting. En: Jensen OT. The sinusbone graft (2ª ed). Quintessence: Chicago 2006. pag: 201-9.

22 Zijderveld SA, Zerbo IR, van der Bergh JPA, Schulten EAJM, ten Bruggenkate CM. Maxillary sinus flooraugmentation using a beta-tricalcium phosphate (Cerasorb) alone compared to autogenous bone grafts.Int J Oral Maxillofac Implants 2005; 20: 432-40.

23 Mardas N, Chadha V, Donos N. Alveolar ridge preservation with guided bone regeneration and a syntheticbone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial.Clin. Oral Impl. Res.21, 2010; 688–698.

24 Ormianer Z, Palti A, Shifman A. Survival of immediately loaded dental implants in deficient alveolar bonesites augmented with beta-tricalcium phosphate. Implant Dent 2006; 15: 395-403.

25 Ogose A, Hotta T, Kawashima H, Kondo N, Gu W, Kamura T, Endo N. Comparison of hydroxyapatite andbeta tricalcium phosphates as bone substitutes after excision of bone tumors. J Biomed Mater Res 2005;72B: 94-101.

26 Linovitz RJ, Peppers TA. Use of an advanced formulation of beta-tricalcium phosphate as a bone extenderin interbody lumbar fusion. Orthopedics 2002; 25 (suppl): 585-589.

27 Boix D, Weiss P, Gauthier O, Guicheux J, Bouler JM, Pilet P, Daculsi G, Grimandi G. Injectable bonesubstitute to preserve alveolar ridge resorption after tooth extraction: a study in dog. J Mater Sci MaterMed 2006; 17: 1145-52.

28 Sela MN. Steinberg D. Klinger A, Krausz AA. Kohavi D. Adherence of periodontopathic bacteria tobioabsorbable and non-absorbable barrier membranes in vitro. Clin Oral Impl Res 1999: 10: 445-52.

29 Szabo G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabas J, Néemth Z, et al. A prospectivemulticenter randomized clinical trial of autogenous bone versus beta-tricalcium phosphate graft alone forbilateral sinus elevation: histologic and histomorphometric evaluation. Int J Oral Maxillofac Implants 2005;20: 371-81.

30 Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting withbetatricalcium phosphate in humans: desnity and microarchitecture of the newly formed bone. Clin OralImpl Res 2006; 17: 102-108.

31 Trisi P, Rao W, Rebaudi A, Fiore P. Histologic effect of pure-phase beta-tricalcium phosphate on boneregeneration in human artificial jaw bone defects. Int J Perio Rest Dent 2003; 23: 69-77.


Clinical case of alveolar ridgepreservation with alloplasticmaterial: Results at 6 months Selene P. Navarro Suárez. Odontologist. Master in dental surgery, Seville.Daniel Torres Lagares. Co-director, Master in dental surgery course, Seville.Jose Luis Gutiérrez Pérez. Co-director, Master in dental surgery course, Seville.

The aim of this study is to demonstrate the resultsof treatment with dental implants placed afterusing bone filling biomaterial: beta-tricalcium phos-phate (RTR bone grafting material - Septodont).As is known, when the absence of a tooth is tobe restored through a dental implant after extrac-tion, even though the implant is not placedimmediately for a reason, e.g. infection in thedental alveolus, the alveolus is preserved tominimize bone resorption as far as possible.The postextraction resorption or bone lossmainly occurs in the vestibular wall. The measu-rements were made at 1.24 mm (vertical) and3.79 mm (horizontal).1 Some authors estimatethat 50% of the resportion volume occurs inthe 12 months following the extraction and thattwo-thirds of this volume are lost in the firstthree months.2 The need to maintain hard andsoft tissue means that it is crucial to avoid orminimize the bone resorption caused by theloss of a tooth.

Current studies indicate that, using the socketpreservation technique, it is possible to reducethis loss of volume by around 1 mm verticallyand around 3 mm horizontally.3 In the caseshown here, the patient presented an infectedalveolus due to failed endodontic treatment andirreparable fracture. Given the risk involved inplacing an implant in these conditions, it wasdecided to carry out the procedure in a secondsession. In these cases, the preservation of thealveolus is highly recommended to avoid boneresorption as far as possible. From among thetechniques available, we opted for filling withbiomaterial of choice. The different steps takenare documented in a previous article. Once theregeneration period was over, we took a 3Dimage of the dental arch to plan the placementof the implant, which we describe below.

Introduction

46


47

The implants were placed sixto nine months after the rege-nerative surgery following asurgical protocol similar to theone previously indicated forthe extraction. The 53-year-old female patient wasanaesthetized in the area, acrestal incision made (Fig. 1-4)with mucoperiosteal flap [totalthickness] procedure withoutany vertical incisions. Wevisualised the appearance ofthe regenerated bone (Fig. 5)in line with the 3D image(Fig. 1-3) previously made andstudied. We placed the twoimplants (Figs. 6-8) in accor-dance with the manufacturer'smilling protocol (Straumann®).Finally, the flap was adaptedby suturing and a post-opera-tive image was taken(Fig .9-10). The patient wasadvised to rinse with 0.5 chlo-rhexidine three times a dayfor 10 days, starting from thesecond day. As medical treat-ment, 1 g of amoxicilin every8 hours for 7 days and 600 mgof Ibuprofen every 8 hours fordays. The stitches wereremoved after 10 days. Thepatient was checked over threemonths, and the re-entry andplacement of the healing abut-ments carried out to createthe soft tissue and begin theprosthetic procedure.

Clinical Case

Fig. 1: Control Preoperative radiography ofalveolar preservation.

Fig. 2: 3D study cut.

Fig. 5: Image showing the height and widthof the preserved alveolar ridge.

Fig. 6: Image of implant placementprocess I.

Fig. 7: Image of implant placementprocess II.

Fig. 8: Placement of the two implants in anideal position.

Fig. 9: Immediate postoperative imagewhere the suture is observed.

Fig. 10: Immediate postoperativeortopantomography radiography.

Fig. 3: 3D reconstruction where the heightof the preserved ridge is seen.

Fig. 4: Preoperative intraoral view of thequadrant to be intervened.


48

The dimensional changes in the alveolar ridgefollowing a tooth extraction considerably compro-mise the functional and aesthetic results ofrestorations made in partially edentulous areas.

The restoration of isolated alveoloar defectsusing implants, as is the case here, shows thatbone regeneration through the use of beta-

tricalcium phosphate is an option to be consi-dered, both from the clinical point of view andfrom the patient's perspective.

Following a healing period of between 6-9 monthsit was possible to place the implants without theneed for any other regeneration procedure.4-7

Discussion

The case presented indicates that beta-trical-cium phosphate (RTR bone grafting material -Septodont) can be used successfully for boneregeneration in dental implant treatment.

One of the main advantages of this techniqueis the elimination of the inevitable morbidityand problems associated with autologous bone

graft, both in the intraoral and the extraoralareas.8-11

The patient's opinion on the treatment was verypositive, both on the process itself and on theappearance achieved, and on the functioningobserved after 12 months of monitoring.

Conclusion

Authors:Selene P. Navarro SuárezDentist, University of Seville.Master Oral Surgery,University of Seville.Assistant Professor of the Master of Oral Surgery, University of Seville.Member of the Spanish Society of Oral Surgery (SECIB)Private practice limited to oral surgery.

Daniel Torres LagaresCo-director, Master in dental surgery course, Seville.

Jose Luis Gutiérrez PérezCo-director, Master in dental surgery course, Seville.


49

References01. Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of post-extractional alveolar hard and soft

tissue dimensional changes in humans. Clin Oral Implants Res. 2012 Feb;23 Suppl 5:1-21

02. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes followingsingle-tooth extraction: a clinical and radiographic 12-month prospective study. Int J PeriodonticsRestorative Dent. 2003 Aug;23(4):313-23.

03. Orgeas et al. Surgical Techniques for Alveolar Socket Preservation: A systematic Review. Int. J. OralMaxillofac. Implants. 2013; 28: 1049-1061.

04. Nkenke E, Schulze-Mosgau S,Radespiel M. Morbidity of harvesting of chin grafts: A prospective study.2001. Clin Oral Implant Res 12:495-502.

05. Silva FM, Cortez AL, Moreira RW, Mazzonetto R. Complications of intraoral donor site for bone graftingprior to implant placement. Implant Dentistry 2006. 15, 420-426

06. Nkenke E, Wcisbach V, Winckler E, Kessler P. Morbidity of harvesting of bone grafts for the iliac crest forpreprosthetic procedures: A prospective study. Int J Oral Maxillofac Surg. 2004. 33:157-163.

07. Bagain ZH, Anabtawi M, Karaky AA, Malkawi Z. Morbidity from anterior iliac crest bone harvesting forsecondary alveolar ridge augmentation: an outcome assessment study. Journal of Oral & MaxillofacialSurgery. 2009. 67, 570- 575.

08. Antoun H, Sitbon JM, Martinez H, Missika P. A prospective randomized study comparing twotechniques of bone augmentation: inlay graft alone or associated with membrane. Clinical Oral ImplantsResearch. 2001. 12, 632-639.

09. FriedmannA, Strietzel FP, Maretzki B, Pitaru S, Bernimoulin JP. Histological assessment of augmentedjaw bone utilizing a new collagen membrane compared to standard barrier membrane to protect agranular bone substitute material. Clinical Oral Implants Research 2002. 13, 587-594.

10. Valentini P, Abensur DJ. Maxillary sinus grafting with an organic bovine bone: a clinical report of long-term results. Int J Oral Maxillofac Implants. 2003;18:556-60.

11. Wallace SS, Froum SJ, Cho SC, Elian N, Monteiro D, Kim BS, Tarnow DP. Sinus augmentation utilizinganorganic bovine bone (Bio-oss) with absorbable and nonabsorbable membranes placed over thelateral window: histomorphometric and clinical analysis. International Journal of Periodontics andRestorative Dentistry.2005. 25, 844-852.


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Use of ß-tricalcium phosphate for alveolar preservation; a report on a series of cases.Authors: Medina Ramírez Jorge Michel*, Gabriela Vilar Pineda**, René García Contreras***.Corresponding author: Gabriela Vilar Pineda.

Summaryß-tricalcium phosphate is a high purity material that helps to safely generate bone neoformation after tissue extraction or loss. Preservation treatment was performed using a ß-tricalcium phosphate cone (R.T.R Cone, Septodont, France) in the lower right quadrant, at the lower third molar area (tooth 48), for research purposes; it was kept under observation for periods of 1 week, 1 month and 3 months. In

the quadrant with the R.T.R, favorable bone neoformation process was observed in a shorter time compared to the left quadrant, and a progressive and total reabsorption of the R.T.R was observed after 3 months. The use of ß-tricalcium phosphate is a useful alter-native for post-extraction alveolar preservation, improving the speed of bone regeneration.

*Student of Dentistry at the National School of Higher Studies of the National Autonomous University of Mexico, León Unit (ENES UNAM León Unit). **Specialist in Oral and Maxillofacial Surgery at the ENES of the UNAM, León Unit. ***Doctor of Health Sciences at ENES/UNAM, León Unit.

Case Studies Collection_RTR_Synthesis2.indd 50 31/08/2018 11:01

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Report on a series of cases

Introduction

Four patients were selected to conduct alveolar preservation with the use of ß-tricalcium phosphate (R.T.R) cones; these patients were required to meet certain criteria. The inclusion criteria used for this report were: patients of both sexes, retained third molars Pell & Gregory class I and II subdivision A and B, bilateral, age range between 18 and 22 years, no perio-dontal or periapical disease in the lower molar region, and willingness to perform the alveolar preservation procedure for research purposes. The exclusion criteria used for this report were: patients with uncontrolled systemic diseases, acute infectious processes, pregnant or lactating patients, patients with bone diseases, use of bisphosphonates, and poor oral hygiene.

Patients meeting the admission criteria for the clinics and oral surgery department of the “Escuela Nacional de Estudios Superiores”, of the UNAM, León Unit, were evaluated.

Auxiliary diagnostic studies were performed (Panoramic radiographs, Periapical views), and no disorders being found in any patient, a diagnosis was made in the full series of cases; retained third molars Pell & Gregory class I and II, subdivision A and B, bilateral.

The patients signed informed consent forms in which they are made aware of the diagnosis, treatment plan and possible complications during treatment.

Bone regeneration with alveolar preservation following tooth extraction has been a topic of major significance recently due to the use of dental implants as a method of esthetic and functional rehabilitation;(1) the improvement of regeneration time is therefore a significant issue, and for such purpose alveolar preser-vation techniques using various materials have been proposed (hard and soft tissue grafts) in view of maximizing tissue preservation and minimizing defects.(2)

ß-tricalcium phosphate (ß-TCP) is a synthetic ceramic bone graft material that has been in use in medicine and dentistry for more than 30 years, in the fields of orthopedics, perio-dontology and maxillofacial surgery. Pore size varies from 5 to 500 μm, and the porosity ranges from 20 to 90% depending on particle size. For dental use, particle size is gene-rally less than 100 μm.(3) Used as a graft material, ß-TCP stands in for the mechanism of osteoconduction; when it is used in the

biological process, the material is reabsorbed and replaced by the recipient’s own bone. The interconnection between pores facilitates osteoconduction. When the graft is placed at the receptor site, some serum proteins are absorbed and retained on the surface of the particles, contributing to the subsequent cellular migration that will stimulate a neovas-cularization process in the porous structure.(3) The R.T.R. (Resorbable Tissue Replacement), is composed of ß-tricalcium phosphate, a material used for alveolar preservation after a tooth removal when posterior prosthetic rehabilitation is planned. The objective of the following series of clinical cases was to evaluate the alveolar preservation achieved with the use of R.T.R cones and without the use of R.T.R. by radiographic evaluations at three-month follow-up. Case reporting was conducted in compliance with Case Report Guidelines (CARE).


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Fig. 3: Extraoral photographs (A: frontal B: lateral)


Fig. 4: Intraoral photographs (A: right side B: top C: left side D: bottom)


PATIENT 2

PATIENT 1

PATIENT 3




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Fig. 9: Initial panoramic radiograph, patient 1.






PATIENT 4

Surgical odontectomies of teeth 38 and 48 were performed under local anesthesia by infiltration with lidocaine and epinephrin 2%, 1:100,000; a Newman’s incision was performed, the muco-periosteal flap lifted, osteotomy and odon-tectomy conducted, the cavity washed, and a cone of ß-tricalcium phosphate (R.T.R) placed in the residual alveolus of tooth 48; on the

opposite side the lower left quadrant in the area of tooth 38 was left with nothing placed inside the alveolus, and both sides were sutured using polyglactin 910 4/0; postoperative management with Amoxicillin 500 mg, 1 every 8 hours for 5 days, and Ibuprofen 400 mg, 1 every 8 hours for 3 days; instructions for general postope-rative measures were likewise provided.


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Fig. 13: Surgical procedure(A) Anesthesia, (B) Incision, (C) Preparation of the flap, (D) Ostectomy, (E) Luxation, (F) Extraction, (G) Extraction sample, (H) Residual Alveolus, (I) Septodont ß-tricalcium phosphate, (J) ß-tricalcium phosphate Cone, (K) ß-tricalcium phosphate Cone transport, (L) Application of ß-tricalcium phosphate Cone, (M) Syneresis.

A

D

G

J

M

B

E

H

K

C

F

I

L

Patients were evaluated 7 days after surgery; good evolution was observed, with an adequate healing process underway; radiographically, a mixed image was observed (black and white radiographic image), interpreted as the ß-tri-calcium phosphate cone (R.T.R) in tooth 48, and

a radiolucent image was observed in tooth 38, corresponding to the residual alveolus; after a month of evolution, we were able to observe improved healing. The area treated with R.T.R showed larger areas of radiopacity, interpreted as improved bone neoformation compared to the


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residual alveolar process area at tooth 38, where slower bone formation was observed, consi-dering the greater areas of radiolucency. The third month of observation allowed us to verify the presence of improved bone regeneration,

a radiopaque image of the residual alveolus at tooth 48, in addition to total reabsorption of the material, as indicated by the manufacturer, and reduced bone trabeculation compared to the residual alveolar process area at tooth 38.

1 week

1 week

Od 48 Od 38 Od 48 Od 38

Od 48 Od 38 Od 48 Od 38

1 week

1 week

1 month

1 month 1 month

1 month

3 months

3 months 3 months

3 months

6 months

6 months 6 months

6 months

Fig. 14: Control periapical radiograph patient 1





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Fig. 18: Panoramic radiograph, 3 months, patient 1.




Discussion

Conclusion

Classically, the ideal material considered for bone regeneration has been autologous bone. However, in recent decades new materials of human, animal or synthetic origin have been incorporated into the arsenal, which have revo-lutionized alveolar preservation techniques.(4)

The action of ß-tricalcium phosphate (R.T.R) on alveolar preservation, in comparison to the natural bone healing process, has been proven.(5) As for its regeneration mechanism, ß-tricalcium phosphate (R.T.R) is a biocompa-tible material that would seem to have scaffold action permitting osteoblasts to grow on its surface and invade its structure.(3)

It has proved to be an excellent biomaterial with high success in bringing about the bone rege-neration necessary to maintain adequate space for implant insertion.(6)

When the ß-tricalcium phosphate is reabsorbed, it is replaced by bone that is anatomically and functionally similar to the original bone, thus producing regenerated vital bone tissue, which means that this bone remodeling and matu-ration process, necessary for the functional loading of implants, is not disturbed by the material.(7) Residual elements may occasionally remain, which can be demonstrated clinically and radiologically after 6 months.(8)

The overall results of the study showed that at clinical follow-up, 1 year after the functional loading of implants (6 months after surgery), no failures were observed in either the implants or the various different implant-supported pros-thodontic options.(9)

In light of the case reports discussed above it was thus observed that after 3 months of observation the time of bone neoformation was significantly improved where R.T.R was used,

as compared to the residual alveolar process where no alloplastic material had been placed; R.T.R is thus a choice material for the effective post-odontectomy preservation of alveolar bone.


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Author:

Dra. Gabriela Vilar PinedaDental Surgeon specialized in Oral and Maxillofacial Surgery by the Faculty of Dentistry of the National Autonomous University of Mexico (UNAM) and recertified by the Mexican Council of Oral and Maxillofacial Surgery. Master of Education with focus on Innovation in Teaching Practice. She currently works as a Career Researcher and Holder of the Degree in Dentistry of the National School of Advanced Studies (ENES) at the UNAM Campus León. She actively

participates as an academic in several Continuing Education Programs, recently recognized for her performance in the field of Oral and Maxillofacial Surgery with the distinction of participation in the Scientific Commission of the Mexican Association of Oral and Maxillofacial Surgery.She held the position of Associate Professor of the subject of Pharmacology in the Division of Postgraduate Studies and Research by the UNAM from August 2010 to July 2011.Coordinator of the University Diploma “Professional Update in Oral Surgery for the Dentist of General Practice” in the period of August 2008 to July 201. Coordinator of the Diploma “Training and Update for Dental Assistants” in the period of February 2010 to July 2011, both taught through the Continuing Education Coordination of the Faculty of Dentistry of the UNAM.At the bachelor's level teaches the theoretical-practical subjects of Anatomy-Physiology of the Segment, Head and Neck, Problem-Based Learning, Introduction to Surgical Procedures, Exodontia and Human Anatomy Physiology.In addition, teaches the subject of Cardiopulmonary Resuscitation; within other subjects that have been taught are Exodontia, Oral Surgery, Dental Medical Emergencies and Anesthesia in the period of July 2005 to July 2011 at the Faculty of Dentistry of the UNAM.She was Professor of Pharmacology, Toxicology and Clinical Analysis at the Faculty of Biological Sciences of the Westhill University in the period of August 2008 to December 2009.She also was Professor of Exodontia and Surgery Oral at the Faculty of Dentistry of the Autonomous University of the State of Mexico (UAEM) in the period of September 2005 to March 2006. Among the activities that he has carried out throughout his academic practice are the following: Synodal of professional exams at bachelor´s degree, Tutor and Adviser of thesis to undergraduate students of the Faculty of Dentistry at the UNAM.Tutor of undergraduate students in the programs “BECALOS”, “PARA” and “PRONABES”, all of these by the Faculty of Dentistry of the UNAM and of the National School of Advanced Studies of the UNAM Campus León.In her professional experience she has worked as a Physician assigned to the Oral and Maxillofacial Surgery Service at the Social Security Institute of the State of Mexico and Municipalities (ISSEMYM) from July 2005 to July 2011, simultaneously as a Physician attached to the Oral and Maxillofacial Surgery Service of the Teachers' Union at the service of the State of Mexico in the period of January 2009 to July 2011.She has also worked in a private practice in the “Hospital Angeles Mexico” in the period of October 2004 to April 2012 and currently a private practice in the “Hospital Angeles León”. She has publications in national and international journals with topics with Craniomandibular Dysfunction and Regenerative Medicine, including some studies on Health, Education and Happiness.She has participated as a national and international lecturer in conferences, courses and congresses in the area of Maxillofacial Surgery, with topics such as Orthognathic Surgery, Dentoalveolar Surgery, Implantology, Craniomandibular Dysfunction, Tissue Regeneration and Regenerative Medicine among others.Currently, she is responsible for projects PAPIME (Project Support Program for Innovation and Improvement of Teaching), Multi-centric and International Research Projects and joint projects with the area of Biomedical Engineering of the Autonomous University of Aguascalientes and develops research projects in the area of Craniomandibular Dysfunction and Regenerative Medicine.


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References1. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in

the dog. J Clin Periodontol. 2005;32:212-8.

2. De, P., Ernesto, M., & Briseño, G. (2015). Materiales de injerto substitutos óseos. Fosfato tricálcico ß. Presentación de casos clínicos. [Bone substitute graft materials. ß-tricalcium phosphate. Presentation of clinical cases.]

3. Labanca M, Leonida A, Rodella, Natural synthetic biomaterial in Dentistry: Science and ethics as criteria for their use. Implantologia. 2008; 1: 9-23

4. Jensen SS, Broggini N, Horting-hansen E, Schenk R, Buser D. Bone healing and graft resorption of autograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Impl Res 2006; 17: 237-43.

5. Salgado Castellanos, J., Zea del Rio, D. M., Gonzalez Miranda, J. M., & Velosa Porras, J. (2014). Effectiveness of Alveolar Preservation Techniques over Post-Extraction Socket Compared with and without Socket Preservation. Systematic Review of Literature. Universitas Odontologica, 33(70). https://doi.org/10.11144/Javeriana.UO33-70.etpa.

6. Jensen OT, Garlini G, Bilk D, Peters F. Use of alloplasts for sinus floor grafting. In: Jensen OT. The sinus bone graft (2nd ed.). Quintessence: Chicago 2006. pg.: 201-9.

7. Trisi P, Rao W, Rebaudi A, Fiore P. Histologic effect of pure-phase beta-tricalcium phosphate on bone regeneration in human artificial jaw bone defects. Int J Perio Rest Dent 2003; 23: 69-77.

8. Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting with ß-tricalcium phosphate in humans: density and microarchitecture of the newly formed bone. Clin Oral Impl Res 2006; 17: 102-108.

9. Zijderveld SA, Zerbo IR, van der Bergh JPA, Schulten EAJM, ten Bruggenkate CM. Maxillary sinus floor augmentation using a ß-tricalcium phosphate (Cerasorb) alone compared to autogenous bone grafts. Int J Oral Maxillofac Implants 2008; 20: 432-40.


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We have not found in the international literature any study regarding the use of ß-TCP in the treatment of infrabony pockets in young patients with aggressiveperiodontitis, which are a clinical entity that very rapidly results in the destruction ofalveolar bone with tooth morbidity as a consequence. For this reason the objective ofthis study is to evaluate and analyse the action of ß-TCP (R.T.R.) on infrabony lesions inyoung patients suffering from aggressive periodontitis.

ß-TCP (R.T.R.) and aggressiveperiodontitisDjamila BOUZIANE - Professor, University of Oran, AlgeriaKhadidja L. MAKRELOUF - Professor, University of Oran, AlgeriaMohamed BOUZIANE - Professor, University of Oran, Algeria

IntroductionAggressive periodontitis, a clinical case frequentin the Maghreb, represents the most destructiveform of periodontal diseases which results inbone lysis, dental mobility and then loss of teeth.Their appearance starts early in life causingaesthetic and functional damage.

These diseases are characterised by a anaerobicGram negative flora.There are two classes:• The form localised in the incisors and the first

molars, as shown clinically in Figure 1 and withX-ray in Figure 2.

Fig. 2: Notice the terminal lysis at the level of 21Fig. 1: Clinical aspect


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We perform on each patient a clinical, radiologicaland bacteriological examination followed by asurgical treatment consisting in flap surgerycombined with R.T.R. grafting material (syringe).The clinical evaluation consisted in measuringthe depth of the pockets.The X-ray examination allowed the evaluation ofthe bone level of our patients thanks to the retroal-veolar - panoramic and radiovisiography images.The bacteriological evaluation consisted in sub-gingival specimens and fresh bacterial profilestudy, Gram staining, culture and PCR.The therapeutic schedule consisted in:• Initial therapy (scaling and root planing)• A systemic anti-infectious therapy with amoxicillin

1 g/d and metronidazole 600 to 800 mg/d over10 days.

• A surgical therapy combining flap surgeryand insertion of R.T.R.

• The surgical sequence is the following:- Anaesthesia- Incisions- Careful debridement- Elimination of granulation tissue- Scaling and root planing- In situ placement of R.T.R. using the syringe

presentation- Sutures- Placement of surgical pack- A maintenance phase with clinical and radio-

graphy re-assessments over four years

Case series4 patients were chosen for whom five siteswere treated:• 2 upper sites (16-21) • 3 lower sites (36-46-46)

- The first patient presented a generalisedaggressive periodontitis with a severe intrabonydefect at 21 associated with an extrusionand at the level of 16 a terminal bone lysiswith a pocket depth of 9 mm.

- The second patient suffered from generalisedaggressive periodontitis with class 3 bifurcationinvolvement at the level of 46 as well asmesial and distal pocket depth of 7 to 5 mm.

- The third patient, 17 years old, with localisedaggressive periodontitis and mesial infrabonylesions with a pocket depth of 8 mm.

- The fourth patient, 16 years old, with a loca-lised aggressive periodontitis, presented 5 mmpockets distally at the level of 46.

Materials & methods

Fig. 3: Inflammatory aspect

Fig. 4: Terminal lysis at 21 and 11

• The form generalised to the entire dentition(Fig. 3 & 4).

The size of the bone lesions requires a welltargeted therapeutic strategy.The objective of our work is to choose sites atthe level of the upper or lower incisors and firstmolars of patients suffering from aggressive perio-dontitis with pockets deeper than 5 mm, infrabonydefects that allow the insertion of ß-TCP (R.T.R.).We will test the influence and impact of this subs-titute material on bone behaviour.


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A 19-year-old woman presented with severegeneralised aggressive periodontitis.On a clinical level, this patient presented aninflammatory condition of the maxillary andmandibular gum with migration of 21 (Fig. 5).

On a radiographic level, the panoramic X-ray ofthe maxillary showed infrabony lesions (Fig. 6)with deep lysis at the level of 21 and terminallysis at the level of 16 (Fig. 7).

It was decided to treat 21 and 16 given thesituation of these severe lesions.

The therapeutic schedule adopted is the followingat the level of 21.T0• Etiological therapy + amoxicillin + metronidazole

antibiotic therapy• Surgical phase: flap + bone substitute: R.T.R.

(Fig. 8 & 9)

T 1 year• Clinical and X-ray reassessment. On the X-

ray, filling of infrabony lesion with 25% bonegain. (Fig. 10)

• At this stage the migration treatment wasperformed.

• Orthodontic treatment phase due to migrationof 21 (Fig. 11)

A stabilisation of the bone gain after initiation oforthodontic treatment was observed (Fig. 12)The reassessment of the infrabony lesion at4 years by radiovisiography showed a bonegain of 50% (Fig. 13). A definitive fixation wasperformed.

Case Report no.1

Fig. 5: Clinical inflammatory aspect

Fig. 6: X-ray :Generalised lysis at the level of the maxillary

Fig. 7: Severe infrabony defectat the level of 21

Fig. 8: Incisions - raising of aflap

Fig. 9: Insertion of bone substitute

Fig. 10: Result at1 year

Fig. 11: DFO treatment of migration at1 year

Fig. 12: Stabilisation of bonegain

Fig. 13: RVG 50% bone gain at4 years


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The study of the posterior site (16) in the samepatient showed:• On a clinical level, the probing detected pocket

depths of 9 to 11 mm (Fig. 14). • On the X-ray, a terminal bone lysis (Fig. 15).

The therapeutic schedule of the infrabony lesionof 16 is the following: • Etiological therapy • Surgical phase: mucoperiosteal flap associated

with in situ placement of R.T.R.The surgical treatment sequence:- Incision and raising of the flap (Fig. 16) - Debridement of lesion - Elimination of granulation tissue - Polishing and planing of root- Insertion of R.T.R. using the syringe: the

granules are mixed with a few drops of blood(Fig. 17)

- Sutures- Surgical pack (Fig. 18) - Placement of surgical pack

The reassessment at 1 year shows the filling ofthe infrabony lesion (Fig. 19).At 4 years it shows a 50% bone gain (Fig. 20).

Fig. 14: Clinical aspect Fig. 15: Terminal lysis

Fig. 17: In situ placement of R.T.R.

Fig. 19: At 1 yearFig. 18: Surgical pack Fig. 20: At 4 years

Fig. 16: Incision and raising of flap


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Case Report no.2A 18-year-old patient presented with severegeneralised aggressive periodontitis (Fig. 21).The panoramic x-ray showed at the level of 46:Infrabony lesion + bifurcation involvement anddepth of pockets of 7 mm (Fig. 22).

Clinical aspect before surgery (Fig. 23).Placement of R.T.R. (Fig. 24).

The radiography X-ray shows an infrabony lesionassociated with a class 3 bifurcation involvement(Fig. 25). At 15 days the filling material is inplace (Fig. 26).

At 4 years the reduction in the pocket depth isof 4 mm, we noticed the absence of bifurcationinvolvement (Fig. 27).

Case Report no.3A 17-year-old patient presented with localisedaggressive periodontitis (Fig. 28) with an averagepocket depth of 8 mm and mesial infrabonylesion of 36 (Fig. 29).The therapeutic schedule is the following:• Etiological therapy associated with medical

treatment which consisted in a combinationof amoxicillin and metronidazole during 10 days

• Surgical treatment: incision (Fig. 30), raisingof the flap, placement of the bone substitute(Fig. 31).

The results at 1 year (Fig. 32) and at 4 years (Fig.33) are very satisfactory.

Fig. 23: Clinical aspect

Fig. 24: Placement of R.T.R.

Fig. 25: Before treatment

Fig. 26: 15 days after the filling

Fig. 27: Result at 4 years

Fig. 28: Clinical aspect Fig. 29: Deep lysis

Fig. 30: Placement of R.T.R. Fig. 31: Sutures

Fig. 33: At 4 yearsFig. 32: At 1 year

Fig. 21: Clinical aspect Fig. 22: Class 3 bifurcation


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Case Report no.4The 16-year-old patient presented with inflam-matory gum condition (Fig. 34). In the X-ray, weobserved prior to treatment an infrabony defectof 46 with a pocket depth of 5 mm and 25%bone loss (Fig. 35).

For this patient, it was decided to follow thesame therapeutical protocol as previouslydescribed.

At 4 years we see the filling of the infrabonylesion with an absence of periodontal pocketand a normal aspect of the desmodontal space(Fig. 36).

DiscussionThe use of R.T.R. (ß-TCP) allowed:• A reduction in the depth of pockets and an

attachment gain.• A decrease in the dental mobility index.• The panoramic and the visiography X-rays

showed a bone gain with filling of infrabonylesions.

• Modifications of the bacterial biofilm in nume-rous studies (Haffajee and al.) show thatcertain species of the red complex (Tannerelaforsythus, Treponema denticola) and of theorange complex (Prevotella intermedia, Campy-lobacter rectus) can evolve differently.Depending on the surgical debridement, thesespecies can recolonise the sites in a verydelayed manner due to the decrease in their

toxic potential and the modification of theirtissue environment.We thus observed in our patients a decreasein bacteria such as Tannerela forsythus, Prevo-tella intermedia, Porphyromona gingivalisAggregatibacterium actinomycetemcomitans,Treponema denticola at 1 year and 4 years.The flap combined with the filling would be infavour of the restoration of the epithelial barrierat the bottom of the pocket with an almostabsence of the available nutrients essentialfor the red and orange complex bacteria.

• The bone gain obtained would be related tothe use of phosphocalcium derivative bioactivematerials which increase bone formation.

Fig. 34: Clinical aspect Fig. 35: Infrabony defect before treatment Fig. 36: Bone repair


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ConclusionOur work demonstrates that an advanced aggres-sive periodontitis with the presence of terminallysis could be currently treated whereas aboutfifteen years ago tooth extraction was the onlyalternative.A significant improvement of the depth of thepockets, attachment level, decrease in dentalmobility, modification of subgingival bacterialbiofilm and bone gain are the results obtainedat 4 years.

The success of our therapy would not havebeen possible without fighting against the bacte-rial biofilm, or without the full cooperation andconsent of our patients.These diseases constitute a public health problemdue to the speed and severity of their evolutionwith functional consequences and psychosocialrepercussions related to the early loss of teeth.This technique has given excellent results inyoung subjects.

AuthorsProf. Djamila Bouziane: University Hospital Professor (University ofOran/Oran University Hospital) - Head of Department of Periodontology - Headof Department of Dental Surgery - President of the scientific council of thehealth research topic agency - President of the national dental medicineteaching committee - President of the regional speciality teaching committee(Parodontology) - President of the national speciality teaching committee(Periodontology) - Director of the oral biology laboratory - Member of thescientific council of the Oran university academy - ANDRS expert (National

Agency for the development of health research) in charge of building a national health researchprogram - Founder and President of the Société Algérienne de Médecine Dentaire (SAMD,Algerian Dental Medicine society) - Member of the Société Algérienne d’OdontologiePédiatrique (SAOP, Algerian Paediatric Odontology Society) - Member of the National DentalCommittee - Vice-President of the International Conference of French language Deans -Member of the Académie Française de Chirurgie Dentaire (ANCD, French Academy of DentalSurgery) - Leader of numerous research projects.

Mohamed Bouziane: University Hospital Professor (University of Oran/Oran UniversityHospital) - Head of Department of Prosthetics.

Leila Khadidja Makrelouf: University Hospital Professor (Periodontology) (University ofOran/Oran University Hospital).


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References

01. ANAGNOSTOU F., OUHAYOUN J.P. Valeur biologique et nouvelle orientation dans l’utilisation desmatériaux de substitution osseuse. J parodontologie et implantologie orale 19.317-243 2000

02. BAEHNI P.C., GUGGENHEIM B. (1999). Potential of diagnostic microbiology for treatment and prognosisof dental caries and periodontal diseases. Crit Rev Oral Biol Med. 7(3):259-277(1996).

03. BARSOTTI O., BONNAURE-MALLET M., CHARIN H., CUISINIER F., MORRIER J.J., ROGER LEROY V.Tests biologiques en odontologie. Dossiers ADF edit SAGIM-CANALE 6-60-2007.

04. BOUZIANE D. Conférence épidémiologie analytique et prise en charge des parodontites juvéniles.Symposium sur les parodontites agressives de l’enfant et du jeune adulte. Société Française deparodontologie et Académie internationale de parodontologie - Marrakech 01 Juin 2001

05. CHARDIN H., BARSOTTI O., BONNAURE-MALLET M. Microbiologie en Odonto Stomatologie Edit Maloine2006.

06. CHARON J.A., SANDELé P., JOACHIM F. Conséquences pratiques des nouveaux moyens de diagnosticen parodontie Inf. Dent. M. 5 (12) 873-883-1993.

07. GIBERT P., TRAMINI P., BOUSQUAT P. H., MARSAL P. Produits antibactériens d’usage local en parodontieAOS n° 212 : 455-465-décembre 2000.

08. HAFFAJEE A.D., TELES R.P., SOCRANSKY S.S. The effect of periodontal therapy on the composition ofthe subgingivalmicrobiota. J. Periodontol 2000, 42: 219-258-2006.

09. M. LABANCA and Coll. Biomaterials for bone regeneration in oral surgery: A multicenter study to evaluatethe clinical application of “R.T.R.” Case studies Collection n°7: 4-11 Mars 2014

10. O.H. ARRIBASPLATA LOCONI. Bone regeneration with ß-tricalcium phosphate (R.T.R.) in post-extractionsockets. Case studies Collection n°7: 12-20 Mars 2014

11. MATTOUT P., MATTOUT C. Les thérapeutiques parodontales et implantaires Quintessence Inter 2003.

12. MICHEAU C., KERNER S., JAKMAKJIAN S. Intérêt du phosphate tricalcique ß en parodontologie etimplantologie. Le Chirurgien Dentiste de France: 1308 : 31-38-2007

13. PRINC G., BERT M., SZABO C. Utilisation de substitut osseux ß-phosphate tricalcique. Etude préliminaire.CDF, 2001 ; 1055 : 29-34

14. PRINC G., BERT M., IFI J.C. Utilisation du substitut osseux ß-phosphat tricalcique (ß-TCP résultats a3 ans) Le Chirurgien dentiste de France 1250/1251/23-30 Mars 2006

15. SIXOU M., DUFFAUT D., LODTER JP. Distribution and prevalence of Haemophilus actinomycetemcomitansin the oral cavity. J. BiolBuccal 19: 221-228-1991.

16. SOCRANSKY S.S., HAFFAJEE A.D. The bacterial etiology of destructive periodontal diseases: currentconcepts. J. Periodontol 63: 322-331-1992.

17. TENNE BAUME H. Les matériaux de substitutions osseuses. Dossier ADF - Edit SAGIM CANALE: 5-49-2005.

18. VAN WINKELHOFF A.J. et WINKEL E.G. Microbiological diagnostics in periodontics: biological significanceand clinical validity Periodontology 2000, Vol. 39: 40-52-2005.


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The effects of periodontal infection and itsconsequences, attachment and bone losses,result in the formation of periodontal bonedefects (1,2). Tooth extraction involves twoprocesses, the healing of the alveolus (3) andany change that may appear during post-extrac-tion healing (4). The clinical consequences oftooth extraction are the resorption of the alveolarridge (5) and the pneumatization of the maxillarysinus (6). If the effects of periodontal diseaseand tooth extraction are combined, the conse-quences will be even more severe and willcomplicate tooth restoration (7). The use ofbone grafting materials prevents and/or repairsthe insufficient bone conditions due to thepreviously mentioned situations (8). We will firstevaluate the biological characteristics (9) of the

alloplastic graft material, beta-tricalcium phos-phate, before presenting Clinical Cases using acommercial presentation of beta-tricalcium phos-phate. The objective of this presentation is todemonstrate the clinical applications of beta-tricalcium phosphate alloplastic graft inperiodontal bone defects and extraction sites.

Modifications in the AlveolarProcess

The most common modifications involving thebone tissue of the oral cavity are: Horizontalbone loss due to periodontal infection, bonedefects caused by periodontal disease, toothextraction resulting in vertical and horizontal

Introduction

This case report presents a brief review of bone loss due to periodontal infection andtooth extraction, and evaluates the biological characteristics, description and indicationsof an alloplastic graft material, beta-tricalcium phosphate, as an alternative treatment intwo clinical cases.

Alloplastic Grafts - Beta-tricalciumphosphate Presentation of clinical casesMario Ernesto García-BriseñoDDS and Professor in Periodontics - Autonomous University of Guadalajara (UAG), Mexico


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resorption, pneumatization of the maxillarysinus and a combination of these. The clinicalconsequence of these conditions are inappro-priate bone dimensions for prosthetics onnatural abutment teeth and the placement ofits substitutes, dental implants (10).

Periodontal bone defects

As a result of inflammatory and immune reac-tions to the presence of bacterial plaque andthe way in which it progresses apically overthe cement surface in one of the periodontalattachment components, the alveolar bone,specific patterns of destruction can be observed.These patterns depend mainly on the type ofsubgingival bacterial plaque and the anatomicalcharacteristics of the alveolar process (11).Basically there are two bone loss patterns,horizontal or vertical forms. The vertical formof bone loss has been described as intrabonyloss and the resulting defects have been histo-rically classified according to the number ofbone walls lost: one, two or three-wall intrabonydefects. Other bone loss patterns have beendescribed as osseous craters and circumferentialdefects. The special anatomy of molars andpremolars involves furcations as a specialcondition in periodontal defect (12).

Tooth extraction

The consequences of tooth extraction representspecific conditions and a special challenge inconventional restorative dentistry and oral reha-bilitation, especially with the use of dentalimplants (13). Whether in case of single ormultiple implants - as abutments for fixedbridges and/or removable prosthesis – or incomplete oral rehabilitation, the bone loss thatfollows tooth extraction in alveolar area or inedentulous arch represents a clinical challenge(14). The consequences of this biologicalprocess are both functional -which complicatesthe prosthesis design - and aesthetic, especiallyin the anterior zone. After tooth extraction, the

alveolus has a very high and predictable chanceof healing in a natural and healthy way withoutany intervention. The biological principle ofthe alveolus repair is based on the formationof a blood clot that covers it completely. Post-extraction healing process has been accuratelydescribed. The stages of this natural processmay be summarised in the following manner: At 30 minutes: clot; at 24 hours: formation ofblood clot and haemolysis; at 2-3 days: forma-tion of granulation tissue. At 4 days: increasein fibroblast density and epithelial proliferationover the edge of the wound and presence ofosteoclasts indicating the alveolus remodelling.At 1 week: defined vascular network and matu-ring connective tissue; osteoid formation inthe bottom of the alveolus. At 3 weeks: denseconnective tissue; full epithelial cover. At2 months: full bone formation is complete butwithout reaching the original height (15,16).

Graft Material Characteristics

Autogenous bone is the only graft materialthat meets the requirement of being osteogenicactivating new bone formation via viable osteo-genic cells (Periostium osteoblasts, endostium,bone marrow cells, perivascular cells and undif-ferentiated and/or stem cells) which aretransplanted with the material and is consideredas the "Gold Standard" as it also has osteoin-ductive and osteoconductive properties (17,18).The term “Osteoinduction” implies the biologicaleffect of inducing differentiation of pluripotentundifferentiated cells and/or potentially induciblecells to express the osteoblast phenotypeleading to new bone growth both within bonetissue and in ectopic sites. i.e. sites in whichthere is no natural bone formation. Even thoughthere are several molecules able of inducing"de novo" bone tissue formation, the BoneMorphogenetic Protein (BMP) is the main proteininvolved (19). The term “Osteoconduction”refers to the characteristic of the graft materialto act as a scaffold or mesh on which existingbone cells can proliferate and form new bone.In the absence of this supporting structure


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provided by the material, the defect or bonesurface would be filled or covered by fibroussoft tissue. The porosity, pore size, shape,particle size and physical/chemical characte-ristics influence the biological effects of celladhesion, migration, differentiation and vascu-larisation at the receptor site (20,21).

Classification of graft materialsby origin

Autogenous materials or Autografts are tissuesfrom the same individual transplanted fromone site to another. Viable cortical orspongy/medullar bone is commonly used inperiodontology and maxillofacial surgery. Allo-genic materials or Allografts are tissue fromone individual of the same species; usually viaa freeze-drying process; bone and skin are themost common ones. Xenografts are tissuefrom different species; mainly mineral bonecomponent or collagen. Alloplastic graft mate-rials are synthetic materials, i.e. they aremanufactured by industrial processes and themost representative in medical dental use areHydroxyapatite, ß-Tricalcium Phosphate andBioactive glasses or polymers (22).

Beta-tricalcium phosphate

Beta-tricalcium phosphate (ß-TCP) is a syntheticceramic bone graft material which has beenused in orthopaedic and dentistry -periodon-tology and maxillo-facial surgery - for morethan 30 years (23). ß-TCP can be treated duringthe manufacturing process so that it has astructure similar to the bone mineral component,either in a block or in particles similar to spongyor trabecular bone (24). This structure hasrandomly interconnected pores. Porosity mayrange from 20% to 90%. The variation in poresize ranges from 5µm to 500µm depending onthe particle size. The particle size in dental useis generally inferior to 1000µm. The mechanismof action of ß-TCP as a graft material is via

osteoconduction with the subsequent resorptionand replacement by host bone. (25) Osteo-conduction is facilitated by the interconnectionbetween pores. In the biological process thematerial is resorbed and replaced by bonefrom the receptor individual. When the graft isplaced in the receptor site, serum proteins areadsorbed on the surface of the particles, whichlater favours cell migration to initiate neo-vascularisation in the porous structure. Overtime, the particles inferior to 1 micron start todissolve and are then resorbed in a processmediated by phagocytic cells, thus allowingbone deposit over the material. The level ofporosity and the particle size will define theresorption rate and the bone replacementprocess which occurs in 9 to 12 months inaverage (26).

Case Report no.148-years-old male patient in general good healthconditions with two localized areas presentingsome discomfort since a couple of monthsmainly in tooth 15 where the patient refersrecurrent swelling but without need to takeanalgesics. A full periodontal examination revealsa localized distal periodontal probing of 10 mm.with bleeding and suppuration and a mildredness (Fig. 1).

Fig. 1: Bleeding and suppuration in 10 mm pocket in tooth 15


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On X-ray examination a wide distal intrabony-two walls defect is present(Fig. 2). The previousroot canal treatment seems without complica-tions in the periapical area. The localizedperiodontal attachment loss and the overallperiodontal health could support the etiologyof pulpar complication i.e. a lateral canal sincethe patient report at least 8 years of root canaltreatment after a painfull episode in the tooth.

A flap debridement procedure is indicated andit is confirmed the bone defect and irregularbone loss in the vestibular cortical plate. (Fig. 3).

With the pulpar involvement as main etiologyan effort is done to find clinical evidence i.e.localized area of resorption and/or lateral foramenwithout confirmation. It is decided to use ß-tricalcium phosphate “R.T.R.” (Septodont) asa graft material. (Fig. 4).

Fig. 2: Initial X-ray showing the intrabony-two walls defect.

Fig. 3: After debridement, scaling and rootplanning a complicated bone loss ispresent.

Fig. 4: ß-tricalcium phosphate “R.T.R.”(Septodont) as a graft material.

Fig. 5: X-ray taken immediately after the surgical procedure showingthe particles of ß-tricalcium phosphate “R.T.R.” (Septodont) in thedefect.

Fig. 6: X-ray six months post-surgery where the particules of ß-tricalcium phosphate “R.T.R.” (Septodont) has been replaced withrecently formed trabecular bone and the bone defect appears withsome lateral reduction.


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Fig. 10: X-ray taken immediately after thesurgical procedure showing ß-tricalciumphosphate “R.T.R.” (Septodont) in the bonedefect and mesial root alveoli

Fig. 11: 6 months of clinical healing. Fig. 12: X-ray 6 months post-surgery wherethe particles of ß-tricalcium phosphate“R.T.R.” (Septodont) have been replaced byrecently formed trabecular bone in the bonedefect and mesial root alveolar.

Case Report no.2A second problem is identified at the periodontalexamination in tooth 46 and confirmed with theX-ray. An extensive root resorption on the distalroot is present (Fig. 7) with any symptom reportedby the patient except some discomfort and“bad taste” occasionally. The root canal treatmentwas done at the same time than tooth 15 (eightyears before). The clinical condition makesdifficult to try endodontic retreatment or othertreatment options like hemisection, the extraction

is indicated. In order to avoid the collapse ofthe residual alveolar bone and the socket, parti-cles of ß-tricalcium phosphate “R.T.R.”(Septodont) is used as graft material. (Fig. 8,9).

ConclusionIn concepts of Osteogenesis, remains todaystill open the debate as to which type of currentlyavailable bone grafting material is the best.

Fig. 7: X-ray showing extensive rootresorption on the distal root of tooth 46.

Fig. 8: Clinical view showing the extensivebone loss in the residual ridge after thetooth extraction. Notice the minimal widthat the crestal area in the buccal and lingualplates and the attachment loss at themesial root of tooth 47.

Fig. 9: Composite blood clot and ß-tricalcium phosphate “R.T.R.” (Septodont)used as graft material prior the suture. In thearea of resorption a cone shaped ß-tricalcium phosphate “R.T.R.” (Septodont)is used and in the mesial root alveolusparticles of ß-tricalcium phosphate “R.T.R.”(Septodont) are used.


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Author: Dr Mario Ernesto García-Briseño DDS at Universidad Autónoma de Guadalajara, México, 1976. Certificate program in Periodontology at Universidad Nacional Autónoma deMéxico 1985-87.Director and Professor of the certificate program in Periodontology since 1992to date at Universidad Autónoma de Guadalajara School of Dentistry.Professor of Periodontology at certificate programs in Endodontics,Orthodontics, and Oral Rehabilitation since 1992 at Universidad Autónoma de

Guadalajara School of Dentistry. Founder and President of the Mexican Association of Periodontology 1996-98. Founding member and Secretary of the Mexican Board of Periodontology 1996/2001. Academy affairs coordinator College of Dental Surgeons of Jalisco 2000/2004. Founder and academic coordinator of the College of Periodontics GDL. National and international lecturer. Private practice in Periodontics and Implant Dentistry.

References01. Listgarten MA. Pathogenesis of periodontitis. J Clin Periodontol. 1986; 13: 418-425.

02. Waerhaug J. The angular bone defect and its relationship to trauma from occlusion and down growth ofsubgingival plaque. J Clin Periodontol 1979: 6: 61-82.

03. Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol 1966;21:805-813.

04. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent1967;17:21-27.

05. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. PartI. Technique and wound healing. Compend Contin Educ Dent 1983;4:437-453.

06. Smiler DG, Johnson PW, Lozada JL, et al. Sinus lift grafts and endosseous implants. Treatment of theatrophic posterior maxilla. Dent Clin North Am 1992;36:151-186.

07. Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenancefollowing tooth extraction. Report of 10 cases. J Periodontol 1997;68:563-570.

08. Mellonig, JT. Autogenous and Allogeneic Bone Grafts in Periodontal Therapy. Crit Rev Oral Biol19923(4):333-352

09. Jarcho M. Biomaterials aspects of calcium phosphates. Properties and applications. Dent Clin North Am1986;30:25–47.

10. Dhingra K. Oral Rehabilitation Considerations for Partially Edentulous Periodontal Patients JProsthodontics 21 (2012) 494–513

11. Listgarten MA. Pathogenesis of periodontitis. J Clin Periodontol. 1986; 13: 418-425.

12. Waerhaug J. The angular bone defect and its relationship to trauma from occlusion and down growth ofsubgingival plaque. J Clin Periodontol 1979: 6: 61-82.

13. Zitzmann NU, Krastl G, Walter C, et al: Strategic considerations in treatment planning: deciding when totreat, extract, or replace a questionable tooth. J Prosthet Dent 2010;104:80-91

14. Craddock HL, YoungsonCC, Manogue M, Blance A. Occlusal Changes Following Posterior Tooth Loss inAdults. Part 2. Clinical Parameters Associated with Movement of Teeth Adjacent to the Site of PosteriorTooth Loss J Prosthodont 2007;16:485-494.

15. Amler MH. The time sequence of tissue regeneration in human extraction wounds. Oral Surg . 1969 27;309-318

16. Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol 1966;21:805-813.


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References17. American Academy of Periodontology. Glossary of Periodontol Terms, 4th ed. Chicago: American Academy

of Periodontolgy; 2001;44.

18. Reynold MA, Aichelmann-Reidy ME, Branch-Mays GL. Regeneration of periodontal tissue: Bonereplacement grafts. Dent Clin North Am 2010;54:55-71

19. Urist MR. Bone: Formation by autoinduction. Science 1965;150:893-899.

20. Jarcho M. Biomaterials aspects of calcium phosphates. Properties and applications. Dent Clin North Am1986;30:25-47

21. Hollinger JO, Brekke J, Gruskin E, Lee D. Role of bone substitutes. Clin Orthop 1996;Mar(324):55-65

22. Gross JS. Bone grafting materials for dental applications: a practical guide. Compend Contin Educ Dent.1997;18:1013-1036

23. Labanca M, Leonida A, Rodella FL Natural or synthetic biomaterials in Dentistry: Science and ethic ascriteria for their use. Implantologia 2008; 1:9-23

24. Metsger D.S. et al. (1982). Tricalcium phosphate ceramic--a resorbable bone implant: review and currentstatus. J Am Dent Assoc.105: 1035-1038.

25. Jensen SS, Broggini N, Hjorting-Hansen E, Schenk R, Buser D. Bone healing and graft resorption ofautograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometricstudy in the mandibles of minipigs. Clin Oral Implants Res 2006; 17:237–243.

26. Artzi Z, Weinreb M, Givol N, et al. Biomaterial resorption rate and healing site morphology of inorganicbovine bone and beta-tricalcium phosphate in the canine: A 24-month longitudinal histologic study andmorphometric analysis. Int J Oral Maxillofac Implants 2004;19:357–368.


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Periodontal intraoseousdefects and post-extractioncompromised socket.Treatment with BetaTricalcium phosphate C.D.E.P. Mario Ernesto García Briseño

The inflammatory response as a result of perio-dontal infection leads to the loss of tooth supporttissues1. The alveolar bone and its three compo-nents, cortical plates, trabecular bone andbundle bone (alveolar bone proper), are lostthrough periodontal infection2. Other conditionscan worsen the periodontal condition, mainlyendodontic, prosthetic and traumatic compli-cations3,4,5. When the tooth extraction is indicated,the anatomic characteristics of the alveolus,the associated lesion and phenotype of theperiodontal tissues can lead to a healing of thealveolar ridge with an inadequate morphology

to the replacement of the lost tooth withfixed/removable prosthetics and/or dentalimplants6,7,8. Restoration of adequate conditionsin the periodontium destroyed by periodontalinfection to preserve the dentition in health andfunction9,10, and/or maximizing the healing condi-tions in the alveolar ridge post extraction forprosthetic restoration11,12, is indicated with theuse of graft materials. It provides predictableresults, safe use and no availability restrictions.These characteristics are present in the syntheticbone graft substitute R.T.R. (beta tricalcicumphosphate)13,14,15,16.

Introduction

The use of safety graft materials, with predictability and availability, is indicated inintraoseous defect treatment and in tooth extractions where the healing of the alveolarridge is compromised. A clinical case is presented with both conditions and the osseousgraft substitute, R.T.R., is used in their treatment.


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62-year-old patient with recurrent periodontaldisease without infection control after a previoustreatment in February 2007. The main concernis “I do not want to lose my teeth”. The clinicalaspect shows high plaque score, signs of inflam-mation, bleeding on probing, periodontalattachment lost and, radiographically, bone lost,pathologic migration and inadequate occlusalrelations (figs. 1,2). At the beginning of theretreatment the patient was instructed aboutthe problem with emphasis on infection controlby meticulous daily plaque control and oralhome care. Once the change in attitude andcompromise were noted, the treatment planwas initiated.

DiagnosisChronic generalized periodontal disease withadvanced periodontal attachment lost.

Treatment planFlap debridement and scaling and root planingin superior arch and scaling and root planingalone in lower arch. Prognosis in the anterosu-perior segment is reserved.

Procedure descriptionAnterosuperior segment. Flap debridement andscaling and root planning filling the osseousdefects with bone graft substitute, R.T.R, andcollagen membrane (Figs. 3,4).

Clinical Cases

Fig. 1

Fig. 2

Fig. 3 Fig. 4


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HealingThe initial radiographs show bone loss and, inradiographs 10 months later, the bone-fill in thedefects is evident (Fig. 5). Initial clinical viewand healing (Fig. 6).

In the lower right quadrant, extraction of tooth46 is depicted. The distal alveolus and bonedefect with loss of the vestibular plate was

filled with bone graft substitute, R.T.R. cones.The blood clot covers the intact alveolus of themesial root (Fig. 7).

Figure 9 shows the complete osseous filling ofthe osseous defect and the compromised socketpost extraction at the time of the implant surgerywith bone regeneration at 9 months, and radio-graphic evidence.

Fig. 5 Fig. 6 Fig. 7

Fig. 9Fig. 8: View of the radiographic initial lesion.


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Loss of periodontal attachment and the conse-quent alveolar bone destruction resulting fromthe periodontal infection require procedures toprovide periodontal regeneration. This goalrequires an accurate diagnosis of the conditionand high practitioner skills. Predictability isrestricted to certain situations. The loss of thebone morphology in the residual ridge postextraction is worse if combined with periodontalattachment loss, extraction procedure compli-

cations, periapical lesions and/or traumaticevents. Prevention and improvement of thehealing post extraction is a common procedurewith restorative, prosthetic and implant dentistry.The use of a bone substitute graft material likebeta tricalcium phosphate (R.T.R., Septodont)ensures biologically secure procedures, predic-tability in results and total availability. The clinicalresults are adequate and scientific evidence-based.

Conclusion

Authors:Mario Ernesto García BriseñoGraduated from the Universidad Autónoma of Guadalajara as a Dental Surgeon(1971-1976).Specialty in Periodontics at the Universidad Nacional Autónoma of México(1985-1987).Coordinator of the specialty program in Periodontology at the Universidad

Autónoma of Guadalajara from 1993 to 2015 (22 years).Professor of the Pathogenesis of Periodontal Disease I and II, Etiology of Periodontal Disease,Occlusion, IV Periodontics, Clinical Cases I and II Seminar and Interdisciplinary Seminar in thePeriodontics Specialty of the Autonomous University of Guadalajara from 1993 to date.Instructor in the Periodontics specialty clinic from 1993 to date (24 years).Professor of the Periodontics Course in the Specialties of Endodontics, Oral Rehabilitation andOrthodontics from 1993 to 2015.Founding Member of the Mexican Association of Periodontology and President Biennium 1996-1998).Founding Member and Secretary in the first board of directors of the Mexican Council ofPeriodontics 1996.Certificate no. 005 of the Mexican Board of Periodontics from 1996 to date.Founder and Academic Coordinator of Periodontology GDL, A.C. College of Periodontist from2005 to date.Prize Jalisco Dentistry 2002.Opinion leader at Crest Oral B.Leader of opinion in Septodont Mexico.International lecturer and author of 3 publications of the company Septodont, France.Member of the Academy of Osseointegration since 2015.Member of the American Academy of Periodontology 1989 to 2010.Author of 10 publications in national and foreign journals and 3 international presentations(Webinar) (Coa, Septodont and CMD).Director and private practice in Professional Periodontology from 1987 to date.


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References01. Listgarten M A: Patogenesis of periodontitis. J Clin Periodontol 1986;13:418-425.

02. Waerhaug J. The angular bone defect and its relationship to trauma from occlusion and down growth ofsubgingival plaque. J Clin Periodontol. 1979;6:61-82.

03. Iqbal MK, Kim S. A review of factors influencing treatment planning decisions of single-tooth implantsversus preserving natural teeth with nonsurgical endodontic therapy. J Endod. 2008;34: 519-529.

04. Zitzmann NU, Krastl G, Walter C et al. Strategic considerations in treatment planning: deciding when totreat, extract, or replace a questionable tooth. J Prosthet Dent. 2010;104:80-91.

05. Hiatt WH. Pulpal periodontal disease. J Periodontol. 1977;48:598-609.

06. Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol.1966;21:805-813.

07. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent.1967;17:21-27.

08. Lekovic V, Kenney EB, Weinlaender M et al. A bone regenerative approach to alveolar ridgemaintenance following tooth extraction. Report of 10 cases. J Periodontol. 1997; 68: 563-570.

09. Bowers GM, Granet M, Stevens M, Emerson J, Coria R, Mellonig J et al. Histologic evaluation of newattachment in humans. J Periodontol. 1986; 75: 280-293.

10. Hammerle CH. Membranes and bone substitutes in guided bone regeneration. In: Lang NP, Karring T,Lindhe J, eds. Proceedings of the 3rd European workshop on periodontology. Implant dentistry. Berlin:Quintessenz Verlag; 1999. pp.468-499.

11. Avila-Ortiz G, Elangovan S, Kramer KWO, D. Blanchette, Dawson DV. Effect of Alveolar RidgePreservation after Tooth Extraction: A Systematic Review and Meta-analysis. J Dent Res. 2014 93:950-958.

12. Orgeas GV, Clementini M, De Risi V, de Sanctis M. Surgical Techniques for Alveolar Socket Preservation:A Systematic Review Int J Oral Maxillofac. 2013;28:1049–1061.

13. Labanca M, Leonida A, Rodella FL. Natural or synthetic biomaterials in dentistry: science and ethic ascriteria fortheir use. Implantologia. 2008; 1: 9-23.

14. Metsger DS et al. Tricalcium phosphate ceramic. a resorbable bone implant: review and current status. J Am Dent Assoc. 1982; 105: 1035-1038.

15. Jensen SS, Broggini N, Hjorting-Hansen E, Schenk R, Buser D. Bone healing and graft resorption ofautograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometricstudy in the mandibles of minipigs. Clin Oral Implants Res. 2006; 17: 237-243.

16. Artzi Z, Weinreb M, Givol N et al. Biomaterial resorption rate and healing site morphology of inorganicbovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study andmorphometric analysis. Int J Oral Maxillofac Implants. 2004; 19: 357-368.


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Sinus Floor Augmentation with ß-Tricalcium Phosphate(R.T.R. Septodont)Mario Ernesto García-BriseñoDDS and Professor in Periodontics - Autonomous University of Guadalajara (UAG), Mexico

History

Resorption of the alveolar process and thepneumatization of the sinus in the posterioredentulous maxilla often represents a clinicalchallenge in restorative/prosthetic treatmentwith dental implants (1).Al-Nawas and Schiegnitz (2014), continuing thework of Klein (3), have proposed a classificationof augmentation procedures in which graft mate-rials are used for bone formation in therapywith dental implants:1) Maxillary sinus floor augmentation, includingthe lateral window technique and transalveolarapproach and, 2) vertical and/or lateral alveolarridge augmentation, including dehiscence-typeand/or fenestration-type defect around theimplant (2).The biological and physiological properties ofthe bone grafts and bone substitute materials

(BSM) have been described in terms of osteoin-ductivity, osteoconductivity and osteogenicity.Osteoconductivity can be described in terms ofa biocompatible scaffold, resorbable at differentspeeds and time, in which the material reactswithout consequences with the tissues at thereceptor site. The three-dimensional structureof the material mostly facilitates vascular proli-feration and, soon after, colonization and growthof osteoprogenitor and osteogenic cells. Thephysical and chemical properties influence boneformation to a lesser degree (4).

Tricalcium Phosphate

With a composition and crystallinity similar tothe mineral phase of bone, Tricalcium Phosphate(Ca3(PO4)2) is a biocompatible and bioresorbablematerial. Biodegradation of the material occursin two ways: dissolution and osteoclastic resorp-

Resorption of the alveolar process and pneumatization of sinus in the edentulous posteriormaxilla are a clinical challenge in the restorative/prosthetic treatment with dental implants.Diverse surgical procedures, bone grafts and substitutes have been used to repair thatclinical situations. Reports have shown radiographic, histomorphometric and clinicalsignificant results with ß-Tricalcium Phosphate. Two clinical cases of sinus flooraugmentation with ß-Tricalcium Phosphate (R.T.R. Septodont) or the subsequent insertionof dental implant are presented in this report.


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Case Report no.1

tion (5). Animal models have shown the resorptionof beta-TCP, its replacement by bone and forma-tion of bone marrow (6). Particle size, microporosityand speed of resorption confer its osteoconductiveproperties and promote the bone formationprocess (7, 8). Placed directly in cancellous bone,it retains its osteoconductive properties, and notissue or systemic reactions were reported (9).Osteoconductive properties have been reportedat ectopic sites (10). For decades, it has beenused in Orthopaedics and multiple dental appli-cations (11-14).

Procedure for maxillary sinus floorelevation

Two authors developed the surgical technique toaugment bone height from the base of the maxillaryfloor (15, 16). Various modifications have beenreported in the literature, but retaining the initialproposal: increasing the vertical dimension from

the maxillary sinus floor with the use of graftand/or bone substitute materials placed betweendetached epithelial membrane and the denudedbone (17, 18, 24). The use of bone substitutematerials has been reported in maxillary sinusfloor augmentation procedures (19), includingbeta-tricalcium phosphate (20-22), with histo-morphometric analysis (23) and simplifiedtechniques (24). Trombelli et al. (2014) report theresults of transcrestal maxillary sinus floor elevationdone with a minimally invasive procedure andcombined with the additional use of deproteinizedbovine bone mineral or beta-tricalcium phos-phate. (24) The survival of dental implants inmaxillary sinus floor augmentation procedureswith ß-tricalcium phosphate has been reported. (1)The authors report an increase in bone quantityassociated with a decrease in grafted materialand the presence of osteoclasts around theremaining particles of material. No complicationsor loss of implants were reported at 12 months.

Female patient, 56 years of age

Fig. 1: Edentulous area, first quadrant. Absence of premolars andmolars lost 12 years ago. Replaced with removable partial denture.

Fig. 2: Occlusal view, quadrant 1.

Fig. 3: Maxillary sinus floor augmentation procedure with lateralapproach and ß-Tricalcium Phosphate "R.T.R." Septodont with bonegraft substitute material (day 0).

Fig. 4: Pre-op X-ray (day 0).


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Fig. 5: X-ray immediately post-op showing the location of the ß-Tricalcium Phosphate on the maxillary sinus floor -radiolucentarea- (day 0).

Fig. 6: X-ray six months after the maxillary sinus floor augmentationprocedure with lateral approach and ß-Tricalcium Phosphate "R.T.R."Septodont as bone graft substitute material. The decrease in theradiolucent area shown in Fig. 6 is obvious, indicating thereplacement of the material with new bone.

Fig. 7: During the surgical procedure (at 7 months) of implantplacement, at the site of 14, the presence of the vestibular corticalplate of inadequate thickness is noted.

Fig. 8: ß-Tricalcium Phosphate "R.T.R." Septodont as bone graftsubstitute material in the vestibular plate of 14. Distal implant in thefirst molar area placed in the area of the maxillary sinus flooraugmented 7 months earlier.

Fig. 9: X-ray immediately after placement of the prosthetic pillars onthe implants. Stability of the implant in the area of 16 was clinicallyproven.

Fig. 10: Prosthetic restoration 10 months after the maxillary sinusfloor augmentation procedure with lateral approach and ß-TricalciumPhosphate "R.T.R." Septodont and 3 months after placement of theimplants.


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Fig. 1: Left atrophic posterior maxilla. Absence of molars lostapprox. 10 years ago. Replaced with removable partial denture.

Fig. 2: Occlusal view of the area.

Fig. 3: Pre-op X-ray. Fig. 4: X-ray immediately post-op showing the placement of the ß-Tricalcium Phosphate on the maxillary sinus floor -radiolucentarea- (day 0).

Fig. 5: Pre-op clinical image 6 months after ß-Tricalcium Phosphategraft "R.T.R." Septodont.

Fig. 6: In the window of the sinus lift procedure done 6 monthsearlier, granules of ß-Tricalcium Phosphate "R.T.R." Septodont areobserved, which indicates partial replacement with new bone.

Case Report no.2Female patient, 55 years of age


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Fig. 7: X-ray image to confirm the cutting depth (2.5 mmØ) of theimplant receptor site at 10 mm (arrow). Partial replacement of thebone substitute material with receptor bone is obvious.

Fig. 8: With osteotomes (Summers technique, 1994) the maxillarysinus floor is lifted 2 mm to achieve insertion of a 12-mm longimplant.

Fig. 9: Implant 12 mm long by 5 mm diameter placed at bone crestlevel.

Fig. 10: X-ray image showing the placement of the implant.

Resorption of the alveolar process and pneu-matization of the sinus in the edentulous posteriormaxilla often represents a clinical challenge inrestorative/prosthetic treatment with dentalimplants (1). Various surgical procedures andgraft materials have been used to correct suchchanges (20-22), including ß-Tricalcium Phos-phate (23). Miyamoto et al. report “… particlesof tricalcium phosphate attract osteoprogenitorcells that migrate into the interconnected micro-pores of the bone substitute material by sixmonths” (25). The stability of the implants placedat the sites has been evaluated (24). A recentsystematic review concludes: "There is a highlevel of evidence that survival rates of dentalimplants placed into augmented areas are

comparable with survival rates of implants placedin pristine bone. For maxillary sinus floor elevation,all investigated bone substitute materialsperformed equally well compared with bone,with high dental implant survival rates andadequate histomorphometric data” (3). The twocases presented show satisfactory results inthe use of the bone graft material, ß-Tricalciumphosphate “R.T.R.” Septodont based on theevidence reported. This, along with the availabilityof the material and its safety in use, make it atherapeutic choice with multiple benefits.

Conclusions


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References01 Schulze-Späte, U., Dietrich, T., Kayal, R. A., Hasturk, H., Dobeck, J., Skobe, Z. & Dibart, S. (2012) Analysis

of bone formation after sinus augmentation using ß-tricalcium phosphate. Compendium of ContinuingEducation in Dentistry 33, 364–368.

02 Al-Nawas B, Schiegnitz E: Augmentation procedures using bone substitute materials or autogenous bone– a systematic review and meta-analysis. Eur J Oral Implantol 2014;7(Suppl2):S219–S234.

03 Klein MO, Al-Nawas B. For which clinical indications in dental implantology is the use of bone substitutematerials scientifically substantiated? Eur J Oral Implantol 2011;4:11–29.

04 LeGeros RZ. Properties of osteoconductive biomaterials: calcium phosphates. Clin Orthop Relat Res2002;(395):81–98.

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Author: Dr Mario Ernesto García-Briseño DDS at Universidad Autónoma de Guadalajara, México, 1976. Certificate program in Periodontology at Universidad Nacional Autónoma deMéxico 1985-87.Director and Professor of the certificate program in Periodontology since 1992to date at Universidad Autónoma de Guadalajara School of Dentistry.Professor of Periodontology at certificate programs in Endodontics,Orthodontics, and Oral Rehabilitation since 1992 at Universidad Autónoma de

Guadalajara School of Dentistry. Founder and President of the Mexican Association of Periodontology 1996-98. Founding member and Secretary of the Mexican Board of Periodontology 1996/2001. Academy affairs coordinator College of Dental Surgeons of Jalisco 2000/2004. Founder and academic coordinator of the College of Periodontics GDL. National and international lecturer. Private practice in Periodontics and Implant Dentistry.


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