DoctorOs 03/2017

CMYK

dental imaging

DoctorOs by Infodent 3/2017 - INFODENT Srl Editorial & Consulting Company - Str. Cassia Nord Km 86,300 01100 Viterbo - Italy - www.infodent.com

Hyperion X9: full empowerment

3-in-1 Full HD Imaging System 3-2017 CB3D. Volume of the entire dental arch and innovative Extended View function with low X-ray exposure.

Extend your view

CEPH.

Compact QuickScan unit with intelligent collimation for CEPH images.

All possibilities, one touch

PAN.

Panoramic images with always-uniform zoom and dedicated sensor.

HD perfection

www.my-ray.com DenTech China · 2017, 25-28 October · Booth A61-A62-A89-A90, Hall 01 · Shanghai World Expo Exhibition and Convention Center, Shanghai, P.R. China MR_X9_DoctorOsInfoInternAug17.indd Inside:

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Immediate implants in extraction sockets with periapical lesions: an illustrated review

牙窝根尖周变病的即刻种植: 一篇有插图说明的述评

24/07/17 10:29

Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance

阻生弯曲上切牙正畸中的直丝弓矫 治器定位技巧

Visit Infodent Booth DenTech China 2017 stand J111-112

www.expodentalmeeting.com LIVE the experience

TOUCH the business

3 days of business and leisure in a stunning location

Meet more than 250 italian and foreign dental companies

LEARN the profession

DIGITALIZE

3 days of training opportunities for all dental professionals

3 days to get into the DIGITAL WORKFLOW

作者投稿指南

迈锐(MYRAY) - 性能卓越、 用户友好的解决方案。 迈锐Hyperion X9 体现了一种模块化概念，覆 盖了从 2D 全景成像、头影测量到具有真正 的全颌弓容积扫描范围的3D 锥形束立体断层 的所有拍摄功能。 迈锐Hyperion X9 通过全局的360°扫描进行 容积采集，可以有效消除所得图像中的伪 影。它可以在极低的X-射线剂量下实现高分 辨率成像，从而提供超凡的图像质量、精致 的细节呈现以及即时的诊断结果。 迈锐Hyperion X9 的扫描视野宽度为Ø 11厘 米，它可以配备大号图像传感器器提供检测 区高度8厘米（可扩展到13厘米）的视野；也 可提供较小版本的传感器器，提供检测区高 度5厘米（可扩展到8厘米）的视野。 其软件可在不到1分钟内处理所有采集数据 并完成重建，包括3D数据。X9所提供图像信 息的数量、质量以及管理这些数据的便捷方 式有助于进行更高效的诊断，并为达到有效 治疗进行有效的规划。 www.my-ray.com

MyRay, solutions which bring you performance and user-friendliness.

Hyperion X9 is a modular concept which covers all aspects from 2D panoramic imaging, through cephalometric exams up to cone beam 3D with true full arch volumetric scan capability.

Hyperion X9 performs a volumetric acquisition with a full 360° scan capable of eliminating the artefacts of the resulting image.

High resolution at extremely low X-ray doses: excellent quality, finest details, immediate diagnosis.

Hyperion X9 scans with a Ø

11 cm FOV, but it can also be equipped with a large image detector, 8 cm high and extendable to 13 cm, or a small version that limits the height of the examined region to 5 cm, extendable to 8 cm.

The software processes all types of acquired data, including 3D data, in less than a minute. The quantity and quality of the information X9 provides and the simple way you can manage that data makes for a clearer diagnosis and helps effective planning, ready for efficient treatment. www.my-ray.com

与卡斯特里尼(CASTELLINI) 一同触摸未来 将公司80年的历史、创新精神及丰富的临 床专业经验熔于一体创造出一流的口腔综 合治疗台Skema 6。

Touch the future with Castellini Eighty years of experience, innovation and clinical expertise concentrated into a high-class unit: Skema 6.

Skema 6 by Castellini, with its high-tech instruments, touchscreen controls and integrated systems, offers dental professionals the ideal tool for high-performance treatment including conservative dentistry, endodontics and implantology. The advanced hygiene devices, fully certified by leading Italian universities, together with a design which ensures functionally ergonomic solutions, enables the dentist to work comfort-

ably, enjoying total peace of mind.

Skema 6 is equipped with Implantor LED, an extremely lightweight induction micromotor with electronic torque control up to 5.3 Ncm, fully autoclavable and suitable for integrated endodontics and implantology.

Full Touch consolle, available as an optional, features a tempered glass display and 5.7” touchscreen interface.

Skema 6 brings dentistry a step closer to the future, with a host of innovative solutions enabling excellent hygiene, total control and enviable comfort, both for patients and medical staff.

卡斯特里尼Skema 6，集高科技器械、触摸屏控制 界面和整合式的内建系统，可满足从牙体牙髓到 种植等各专业口腔医生高品质临床需求的理想工 具。它还可以提供高端卫生消毒设备，经意大利 大学测试认证有效，为医生提供舒适的符合人体 工学的感控解决方案，使他们可以平静专注地对 待患者。 Skema 6 装备的LED光纤种植电马达，其 具有超轻的重量，高达5.3Ncm的扭矩，可耐全面 高温高压灭菌，可用于包括根管及种植等临床应 用。本机还可以选配具有坚固的5.7英寸触摸屏用 户界面的全触摸屏控制器。 凭借高效的卫生学解决方案、全面操控体验以及 令人羡慕的舒适度，无论医生及护士团队均可轻 松体会Skema6带领牙科界更进一步迈入未来。

castellini.com

castellini.com

DoctorOs 牙医 Infodent International •3/2017 Doctor Os 牙医 Infodent International •3/2017

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Technology that innovates Skema 6 combines the best of Castellini technology with the practicality and effectiveness of multiple integrated systems. Ample scope for personalisation ensures the achievement of outstanding clinical and specialist performance via a precise, interactive control panel, available as a Full Touch version with a 5.7” glass display.

Cutting-edge configuration is completed via the availability of highly advanced dynamic instruments, an innovative multimedia system, all the main certified hygiene devices and the latest exclusive functions from Castellini.

DenTech China · 2017, 25-28 October · Booth A61-A62-A89-A90, Hall 01 Shanghai World Expo Exhibition and Convention Center, Shanghai, P.R. China

卡斯特里尼

highlights

赛特伟邦 （STERN WEBER） STERN S320TR

安福士 (ANTHOS) -向全世界牙 医提供无限解决方案的品牌。 A级系列 完整的A级系列口腔综合治疗台的设计宗旨是尽可 能提供最大的灵活性，使牙医可以选择最适合其 操作风格和专业需求的人体工学和功能设置。 A5级可提供6种不同的配置。 适合各种操作风格的 人体工学，整合的安福士品牌器械，脚控和手术 灯的扩展性选择，不同的卫生学系统、可选配置 和颜色主题，从每个方面讲都具有多样的变化。 选择 A7 +级的牙医知道他们可以根据当前和未 来的特殊需求对其口腔综合治疗台进行个性化定 制，无论他们的专业领域属于常规牙科还是种植 科。鉴于搭载了向所有的可整合安福士设备开放 的基础技术配置接口，这款高端的治疗台可以在 现场或在未来与超高性能器械仪器、X-射线装 置、多媒体系统以及先进的卫生学设备相匹配， 达到扩展功能的目的。

基于分体落地式的主体特征，S320TR在保证患者椅 运行的独立性同时，依然具备极高的稳定性和充分的 治疗操作空间。作为来自意大利的最新型号款式，牙 医在诊断上能够获得崭新的操作体验。 赛特伟邦（Stern Weber）以持续开发先进的牙科设备 为基本指导原则（秉持-坚固、紧凑、操作友好方便、 符合人体工程学结构以及自身出色的性能），TR系列 最大限度的为您提供前所未有的丰富的新的机遇。 医生位的良好机动性保证了此种操作风格的完美定 位性和移动操作的优化流畅性。医生位采用铸铝支架 臂，具备出色的稳定性，再加上通过按键操作进行高 度调节，可以让牙科医生从容而安心的工作。由于采 用了最新的数码电子科技，使得S320TR给牙科医生 们带来了最好的操作体验。

www.anthos.com

sternweber.com

ANTHOS. THE BRAND WITH LIMITLESS SOLUTIONS FOR DENTISTS ALL AROUND THE WORLD. The Classe A range Developed to provide as much flexibility as possible, the full Classe A range of units enables dentists to select the ergonomic and functional set-up best suited to their operating style and professional needs.

Classe A5 can be supplied in 6 different configurations. Ergonomics to suit every operating style, integrated Anthos brand instruments, an extensive choice of foot controls and operating

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lights, various hygiene systems, options and colour schemes: versatility in every sense of the word.

Dentists who choose Classe A7 Plus know they can personalise their dental unit according to the specific needs of today and tomorrow, whatever their field of specialization, from conservative dentistry to implantology. Thanks to the underlying technological configuration, open to all integrated Anthos systems, this premium treatment centre can be expanded, immediately or at a later date, with ultra-high performance instruments, X-ray and multimedia systems, and advanced hygiene devices.

Doctor Os 牙医 Infodent International •3/2017

STERN WEBER Stern S320TR Characterised by a floor-mounted unit body, which remains independent from the patient chair and its movements, the S320TR models provide stability and extensive operating space. This latest model from the Italian brand lets dentists explore new capabilities within the diagnostic field.

By taking the guiding principles behind Stern Weber’s advanced dental unit development program – sturdiness, compactness, user-friendliness, ergonomics and performance – the TR Series maximises them as never before

so as to provide you with a wealth of new opportunities.

Excellent manoeuvrability of the dentist’s module ensures perfect positioning and optimises fluidity of the movements associated with this operating style. The outstanding stability of the dentist’s module and its cast aluminium support arm, coupled with a telescopic height adjustment function operated via the keypad, allows the dentist to work calmly and confidently. Thanks to the latest digital electronics, the S320TR brings out the dentist’s very best. sternweber.com

DoctorOs 牙医 Infodent International •3/2017

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作者投稿指南

Victor V286 a lifetime partner

精心挑选优质材料保证持久运行及超凡的可靠性，V286采用铸铝结构部 件来增加稳定性，和注塑塑料工艺来提供出色的表面处理。作为最新款 的公理福口腔综合治疗台，结合了美观设计与最新人体工学及空间利用 理念的V286在欧洲开发并完成工程学测试。高级的电子电路允许最多5 位不同操作者的个性化设置。最新的具有同步功能的病人椅（最大可以 提升190公斤的重量）可确保患者的最佳舒适度，也有柔软的沙发皮垫可 供选配，体现奢华。治疗台可以配备4组可动器械，包括意大利原装进口 的高性能无碳刷电动马达。口腔医生可以通过带有新款三位液晶数字屏 幕的控制面板调整及观察参数和设置。液晶面板可以显示操作状态的细 节，并进行自我诊断。

Built with premium quality materials for lasting service and superb reliability, the V286 boasts cast aluminium structural elements for increased stability and injection moulded plastics to provide an excellent surface finish. Developed and engineered in Europe, the latest treatment centre in the Victor range not only seduces from a design point of view, but can also count on the latest solutions in terms of ergonomics and space-efficiency. Advanced electronics allow extensive personalisation for up to 5 different operators. Synchronised patient chair movements (lift capacity can reach up to 190 kg) enable maximum comfort and soft upholstery is an attractive option. The unit can be fitted with up to 4 dynamic instruments, including the high-performance brushless micromotor manufactured in Italy. Dentists can select operating parameters and visualise key settings on the new, large 3-digit LCD control panel. The LCD display provides details of operating status and includes a selfdiagnostic system.

更多信息请详见www.victordentalequipment.com

More details on www.victordentalequipment.com

公理福V286 – 一生好伙伴

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DoctorOs 牙医 Infodent International •3/2017

Doctor Os 牙医 Infodent International •3/2017

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Contents 目录

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从发表第一篇关于骨结合这一技术与其第一个临床试验 (1、2 ) 至今，人们对对骨结合式种植修复的兴趣已经增长了好多 倍...

20-25 Immediate implants in extraction sockets with periapical lesions: an illustrated review

27-31 阻生弯曲上切牙正畸中的直丝弓矫治器定位技巧 Andreasen等学者在[1971]年给弯曲牙下了一个定义：弯曲牙就是 牙齿的牙冠长轴与牙根比例有严重偏差，这是由于已经形成的硬 体组织相对于发育中的软组织有一个创伤性非轴向移位而造成 的...

32-36 Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance

14-19 牙窝根尖周变病的即刻种植:

一篇有插图说明的述评

• Highlights 1 迈锐(MYRAY) - 性能卓越、用户友好的解决方案。 MyRay, solutions which bring you performance and user-friendliness.

与卡斯特里尼(CASTELLINI) 一同触摸未来 Touch the future with Castellini 3 安福士 (ANTHOS) -向全世界牙 医提供无限解决方 案的品牌。

ANTHOS. The brand with limitless solutions for dentists all around the world

赛特伟邦 STERN S320TR STERN WEBER Stern S320TR 4 公理福V286 – 一生好伙伴 Victor V286 a lifetime partner

27-31 阻生弯曲上切牙正畸中的直丝弓矫治器定位技巧 32-36 Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance.

38-43 ß-磷酸三钙在拔牙后牙槽窝中的应用 44-49 Post-extraction application of beta-tricalcium phosphate in alveolar socket 50-52 长4毫米的种植体在下颚无齿且垂直骨量受限患者中 的运用评估。 手术初步结果

54-56 Evaluation of 4 mm implants in mandibular edentulous patients with reduced bone height.

Surgical preliminary results.

• Industry News

• DenTech Exhibition

10-11 Silfradent: CGF Concentrated Growth Factors: Protocol and characterization 12-13 Silfradent: CGF浓缩生长因子：学术方案和性质特征

58-59 Infodent International for DenTech China: the living magazine project Infodent International 为DenTech China开展互动杂志项目

• Scientific Updates

• Calendar

14-19 牙窝根尖周变病的即刻种植: 一篇有插图说明的述评 20-25 Immediate implants in extraction sockets with periapical lesions: an illustrated review

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DoctorOs 牙医 Infodent International •3/2017

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作者投稿指南

作者投稿指南 本杂志所发表的文章旨在分享和传播国际间牙科领域的知识：阅读Doctor Os Infodent 牙科杂志编辑指南，并将您的手稿发送至我们编辑部的电子邮箱 info@ariesdue.it

Doctor Os 牙医 Infodent International 牙科杂志至作者的投稿信息 基本信息 • Doctor Os Infodent牙科杂志的使命是促进国际间牙科领域 内学术和专业知识的科学文化交流。 • 杂志内的文章将根据以下类型分类：研究（临床，实验和 流行病学研究），文献综述，病例报告，专业更新，新技 术描述。 投稿要求 • 投给本社的手稿不能同时提供给其他出版社或在其他期刊 上出版过。 • 作者的稿件中如有已在另一本杂志上发表过的插图或文本 时，必须提供版权所有者的许可。 该许可必须以书面形式 与手稿一起寄给编辑部。 在没有书面许可的情况下，本 社收到的所有材料将被默认为该作品的所有权属于作者本 人。 • 文章均免费出版，作者亦不从本杂志取得任何形式的报 酬。 • 最终稿件须用电子版本发送至info@ariesdue.it; 本社不予受 理寄出后的修改。 作者背景信息必须包括以下内容 • • • • •

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所有作者的全名 每位作者的完整地址，电话号码和邮寄地址。 学位情况(如 牙科医生, 牙科医学博士, 博士等). 供职单位名称（如牙科学校，伦敦大学等） 已发表过的文字或插图所涉及人员的肖像权。

DoctorOs 牙医Infodent InfodentInternational International•2/2017 •3/2017 Doctor Os 牙医

• 将作品（包括文本和图解）发送至info@ariesdue.it。 • 所有插图必须在文本中有相关信息，并用电子版本TIFF或 JPEG文件形式单独发送，插图尺寸应该在最小3.5厘米（ 宽），最大9厘米（高）的范围内，分辨率为300 dpi。 图 像必须连续编号，并附有相关说明。 • 每篇文章作者的最多数量为6个。 • 文本必须用英文和中文书写，其结构如下。 › 英文和中文的科学标题。 › 作者全名以及各自的专业资格和供职单位。 › 英语和汉语的结构性摘要，包括关键词，研究目的，材 料和方法，结果和结论。 › 用医学术语索引列出英文和中文的关键词。 › 论文的简介与目的。 › 材料和方法，描述要足够详细以便允许其他人可以重复 相同的结果。 研究必须符合赫尔辛基宣言和之后修正 案中的条款。 › 结果 › 讨论和结论 › 参考文献列表中的文献必须按照文本中出现的顺序排 列，并在括号（）中用阿拉伯数字列出。 › 表格，图形，插图和说明。 • 出版的批准由科学委员会授予，如认为有必要，该委员会 可以对文本进行修改。 校对只有在印刷错误的情况下才会 作出纠正，不对原文作任何更改或修改。 • 所有文本的版权属于出版商。作者同意在本期刊上发表文 章，意味着须接受该作品在其他在线或印刷出版物中被全 部或部分出版的可能性。 如需要改变稿件所有权，作者必 须向工作人员提出要求并填写版权声明。对未向出版社明 确提出过要求的手稿，出版商拒绝承担任何责任。 文稿所表达的观点，纯属作者本人见解，不代表本刊之观 点和意见。出版社对发表文章所放任何错误概不负责。 • 原始文本将不予返还。

S320TR Our innovation, your solution.

Your professional needs are evolving all the time, and so are our solutions. We have decades of experience in creating cutting-edge products able to anticipate your every need. Outstanding performance, a 5.7” touch screen control unit and an integrated imaging system allow you to achieve results at the very peak of the profession.

Stern Weber: once again, a solution to match your talent.

www.sternweber.com DenTech China · 2017, 25-28 October · Booth A61-A62-A89-A90, Hall 01 Shanghai World Expo Exhibition and Convention Center, Shanghai, P.R. China

Guidelines for authors

Guidelines for authors The journal publishes articles in order to share and disseminate knowledge among the international dental community: read Doctor Os Infodent editorial guidelines and send your manuscript to info@ariesdue.it

Doctor Os 牙医 Infodent International: information for authors General Info

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• Doctor Os Infodent’s mission is to promote the scientific and cultural exchange of scholarly and professional knowledge in dentistry at an international level.

• The articles will be classified according to the following types: research (clinical, experimental and epidemiological studies), literature reviews, case reports, professional updating, description of new techniques.

Requirements • The manuscripts can’t be offered simultaneously to others publishing houses or published in other journals.

• Authors whose manuscripts include illustrations or texts already published in another journal have to provide the permission from the copyright holder. This permission must be received in writing along with the manuscript. In the absence of it, all the material received will be considered property of the author of the work.

• Articles are published free of charge and any sort of reward for the author is excluded.

• The final drafting of the manuscript must be sent in a digital format to info@ariesdue.it; subsequent amendments will not be accepted.

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Author information must include the following • Full name of all authors.

• Complete address, telephone number and mailing address for each author.

• Degrees (e.g. DDS, DMD, PhD).

• Affiliation (e.g. School of Dentistry, University of London…).

• The permission for texts already published or images depicting people.

• Send the work (text and iconography) to info@ariesdue.it.

• All illustrations must have a reference in the text and be sent in 88

DoctorOs 牙医Infodent InfodentInternational International•2/2017 •3/2017 Doctor Os 牙医

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a digital form as separate TIFF or JPEG files, having a minimum size of 3.5 cm (width) and a maximum size of 9 cm (heigth) at a resolution of 300 dpi. Figures must be numbered consecutively and accompanied by their legends.

The maximum number of authors accepted per article is 6.

The texts must be written in English and Chinese language and structured as follows. › Scientific title in English and Chinese language. › Author(s) name(s) and last name(s) and respective professional qualifications and affiliations. › Structured summaries in English and Chinese including subtitles, aim of work, materials and methods, results and conclusion. › Keywords in English and Chinese, using terms listed in the Index Medicus. › Introduction with the aim of the article. › Materials and methods, described in sufficient detail to allow others to reproduce the results. The study must be done in accordance with the Declaration of Helsinki and subsequent amendments. › Results › Discussion and conclusions › List of references Bibliographical references must be listed in order of appearance in the text and identified by Arabic numerals in parentheses (1). › Tables, graphics, illustrations and legends.

Approval for publication is granted by the Scientific Board, who can make changes to texts if deemed necessary. The proofs must be returned corrected uniquely of misprints, without any changes or modifications.

The literary property of all texts belongs to the publisher.

The author(s) requiring publication in the journal implicitly accepts the possibility of being published, fully or partially, in other online and print publications. To transfer the ownership of the manuscript the authors must ask to the staff and fill the copyright statement. The publisher declines any liability related to manuscripts not expressly requested by the publishing house.

The opinions expressed are the opinions of the authors and do not necessarily reflect the views of the publisher.

The publishing house has no responsibility for any errors in the article published.

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INDUSTRY NEWS Silfradent

CGF浓缩生长因子：学术方案和性质特征 CGF是自体血小板浓缩液，由Sacco在2006年研发, 他借助一个离心机装置（该装置是由意大利 Forli的Silfradent 有限公司生产的MEDIFUGE200离心机）用一个标准化的简易分离法，在没有任何 外源附加物质的情况下, 将它从血液样本中分离出来。该CGF的主要特点在于它的一致性: 是 一个富含纤维蛋白的有机基体, 它可以“捕捉” 血小板、白血球和生长因子, 在再生过程中, 这些 元素都起着很重要的作用。 CGF-（浓缩生长因子） CGF的突出特点： •操作简单, 安全, 经济 •天然- 100％的自体 •粗纤维蛋白基质 •白细胞、血小板和生长因子 •可变的释放动能 •用于骨移植材料矩阵结构中 CGF可以给再生医学领域的操作提供有价值的帮助, 以 加快再生的过程。其实这种生长因子浓缩显示出极大的 可再生性和通用性（Sohn等人, 于2009年）。它的用途 已经被使用于各种不同的情况下和范围内, 从填充拔牙窝 （Tadić等人, 于2014年）, 到填充膀胱切除后的空腔（Mirković等人, 于2015年）, 或用于上颌窦的抬高手术中（Kim 等人 , 于2014年, Del Fabbro等人, 于2013; Sohn等人, 于2011年）。此外, 它还可以单独使用, 或与自体骨粒子或生物材料一起使用（Gheno等人, 于2014 年）。一些学者建议与CGF一起弄湿植入物的表面, 来加速 骨整合（Siebrecht等人，于2002年）。 •用扫描电子显微镜（SEM）研究表明, CGF是一个由薄纤 维状元素和厚纤维状元素够成的纤维蛋白网（Rodella等人, 在2014年提出）。 •组织形态学的研究（由BORSANI, Bonazza等人在 2015年提出）已经使人们能够看到CGF网状纤维蛋白的结 构和CGF中血细胞（白细胞、红细胞和血小板）的分布。 •最后, 对不同的人类细胞系进行体外实验（由 BORSANI, Bonazza等人在2015年提出）的结果证明, 在培养基中加入CGF, 可以起到刺激细胞增殖的作用 （由BORSANI, Bonazza等人, 在2015年提出）。

CGF- 材料 血样采集

1.防腐拭子 2.全套蝴蝶针 3.止血带 4.纱布 5.补丁 6.Vacuette血液收集管（由奥地利克雷姆斯明斯特的Greiner Bio-One国际有限公司生产） 7.试管架 Fig.12i 10

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Fig.12l

CGF是在不添加任何外源性物质的情况下, 在涂有二氧化 硅微粒的聚乙烯试管中（Vacuette试管）制造出来的。采 血后, 立即使用一种特殊的离心机（MEDIFUGE200离心机, 由意大利Forli的Silfradent 有限公司生产）将血液样品进行 离心而得。

CGF MEDIFUGE离心机（Silfradent有限公司生产） 特点 •台式离心机为了专门用于CGF的制备, 该机配备了一个可 以替换可稳速的转子, 并且在加速时始终低于300 RCF。 •MEDIFUGE离心机可以一次放置多达8个用于制造 CGF（纤维蛋白）的试管; •由一个微处理器控制系统来维持恒定的速度; •外加一个具有自通风功能的转子系统, 该系统避免了血液 样品暴露在热源之中; •在试管破裂的情况下, 转子仓、关闭的门和试管夹套子, 都 可以在生物防护方面提供可靠的生物安全性; •试管夹套子和转子都是由易散热、抗静电的材料制成, 因 此, 易于清洗和提取, 置于135℃高压灭菌器内消毒即可; •MEDIFUGE离心机还配备了一个利用UVC反射光的净化 循环系统; •净化时间为在转速1000下持续5分钟; •电子控制发动机及其内部部件无需维护; •噪音水平低于所要求的标准, 不超过57分贝。 CGF离心方法（一次离心法） 30’’加速 2’2700转/735克 4’2400转/580克 4’2700转/735克 3’3000转/905克 33’减速和停车 离心过程结束时, 血液被分成了三个层次:（1）上层, 有被叫做贫血小板血浆的液态血浆（PPP）; （2）红色的下 层, 是由于包含了大部分的红细胞所至（RBC）; （3）中间层, 由三个部分组成的固体CGF: 上部白色, 下边红色部分（至红细胞的距离约0.5厘米）和中间的 “血沉棕黄层*”部分（就是连接白色部分和红色部分的那一 段）（图1 A，B，C）。

CGF-形态特征

网状纤维蛋白 利用电子显微镜（SEM）, 可以观察到网状的纤维蛋白CGF 由薄纤维状元素和厚纤维状元素（图2A）构成。 图2A: 电子显微镜下看到的CGF网状纤维蛋白

苏木精 - 伊红染色体, 使我们能够观察到CGF网状纤维蛋白 的结构（图3）。图像显示, 网状纤维蛋白的结构在血沉棕 黄层和白色层中是不一样的。邻近血沉棕黄层的网状纤维 蛋白的网格显得特别严密紧凑（图3A）, 而远离棕黄层的网 状纤维蛋白的网格则比较粗大（图3B）。

网状纤维蛋白的结构 A）邻近血沉棕黄层；B) 远离棕黄层

血细胞 用迈格林华染色液（图4A）和苏木精 - 伊红（图4B）, 可以 定位到CGF中存在的血细胞。白细胞主要分部在血沉棕黄 层中, 并零散分散在CGF中的其它部分; 尤其是 在CGF的红色部分中; 而红细胞则只存在于CGF的红色部分 内。

图1ＡＢＣ：CGF的分层示意图

图4：A）迈格林华染色液 B）苏木精-曙红

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INDUSTRY NEWS Silfradent

CGF Concentrated Growth Factors: Protocol and characterization The CGF is an autologous platelet concentrate, developed by Sacco, in 2006 and obtained from blood samples through a simple and standardized separation protocol, by means of a specific centrifuge (MEDIFUGE 200, Silfradent srl, Forli, Italy), without the addition of exogenous substances. The main feature of the CGF resides in its consistency: it is an organic matrix rich in fibrin, able to “trap” platelets, leukocytes and growth factors; elements that play an important role in the regenerative processes.

CGF-(Concentrated Growth Factors) Salient features of the CGF: • Simple, safe and economic • Natural - 100% autologous • Thick Fibrin Matrix • Leukocytes, Platelets and Growth factors • Variable kinetics release • Matrix for Bone Graft Material The CGF may be a valuable aid in the field of regenerative medicine, to speed up the process of regeneration. In fact this growth factor concentrate, showed great regenerative properties and versatility (Sohn et al. 2009).

Its use has been proposed in various situations ranging from filling of extraction sockets (Tadić et al., 2014) to the filling of the cavity after cystectomy (Mirković et al., 2015), or in the sinus lift procedure (Kim et al., 2014; Del Fabbro et al., 2013; Sohn et al., 2011). Moreover, it can be used alone or with autologous bone particles or biomaterials (Gheno et al., 2014). Some authors suggest wet the surface of the implants with CGF in order to accelerate the bone-integration (Siebrecht et al., 2002).

• Scanning Electron Microscopy (SEM) studies, have shown that the CGF presents a fibrin network formed by thin and thick fibrillar elements (Rodella et al., 2014).

• Histo-morphological studies (Borsani, Bonazza et al., 2015 submitted) have allowed to see the fibrin network structure and the distribution of blood cells (leukocytes, erythrocytes and platelets) in the CGF. • Finally, in vitro studies using different human cell lines (Borsani, Bonazza et al., 2015 submitted), have shown that the addition of the CGF to the culture medium, stimulated cell proliferation (Borsani, Bonazza et al., 2015, submitted).

CGF - MATERIALS BLOOD COLLECTION 1. Antiseptic swab 2. Complete butterfly 3. Tourniquet 4. Gauzes 5. Patches 6. Vacuette Test Tubes (Greiner Bio-One GmbH, Kremsmunster, Austria) 7. Tube rack

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CGF is obtained using polyethylene tubes (Vacuette Test Tubes), coated with silica micro particles and without the addition of exogenous substances. After collection, the blood samples are immediately centrifuged using a special centrifuge device (Medifuge, Silfradent, Italy).

CGF MEDIFUGE (Silfradent) Characteristics • Benchtop centrifuge dedicated to the CGF production, equipped with an appropriate rotor with alternate and controlled speed and with an acceleration always below 300 RCF. • The medical device MEDIFUGE allows for the use of up to 8 test tubes for the creation of CGF (fibrin); • A microprocessor control system allows for the maintaining of a constant speed; • The exception rotor system with self-ventilation protects the blood sample from heat exposure; •The rotor-holding compartment, the closing door and the test tube-holding jackets guarantee biological safety in terms of bio-containment, in the event of test tube breakage; •The test tube-holding jackets and rotor are built from thermal, antistatic material that is easy to clean, extract and sterilize in an autoclave at 135°; •MEDIFUGE is equipped with a decontamination cycle with UVC reflected light; •Cycle duration 5 minutes at 1,000 revs; •The electronic control engine and its internal parts require no maintenance; •Noise levels fall below the standards required and do not exceed 57 dBa. CGF centrifugation protocol (One step protocol) 30’’ acceleration 2’ 2,700 rpm/ 735 g 4’ 2,400 rpm/ 580 g 4’ 2,700 rpm/ 735 g 3’ 3,000 rpm/ 905 g 33’’ deceleration and stop At the end of the process, three blood fractions were identified: (1) the upper layer, representing the liquid phase of plasma named platelet poor plasma (PPP); (2) the lower layer, representing red blood cells (RBC) because of mainly contains erythrocytes; (3) the middle layer, representing the solid CGF consisting in three parts: the upper white part, the downer red part (about 0,5 cm from RBC) and the middle “buffy coat*” part (interface between white and red part) (Figure 1 A,B,C).

CGF- Morphological characterization FIBRIN NETWORK The use of electron microscopy (SEM), allowed to observe that the CGF fibrin network of the is constituted by thin and thick fibrillar elements (Figure 2A).

Fig.2A: SEM analysis of CGF, fibrin network Hematoxylin-eosin staining, allowed to observe the architecture of the CGF fibrin network (Figure 3). The images showed that the fibrin network and architecture changed moving from the buffy coat* to the white part. In particular, near the buffy coat* the fibrin network was strictly compact (Figure 3A) while far from the buffy coat* became with a larger mesh (Figure 3B).

Fig.3: Architecture of the fibrin network: A) near the buffy coat; B) far from the buffy coat; BLOOD CELLS The May Grunwald Giemsa histological staining (Figure 4A) and Hematoxylin-eosin (Figure 4B), allowed to localize blood cells present in the CGF. White blood cells are mainly located in the buffy coat* and dispersed in it, especially in the red part of the CGF; the red blood cells are present only in the red part of the CGF.

Figure 4: A) May Grunwald Giemsa; B) Hematoxylin-Eosin Fig.1A,B,C: phases of CGF

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13

SCIENTIFIC UPDATE

牙窝根尖周变病的即刻种植:一篇有插图说明的述评

牙窝根尖周变病的即刻种植: 一篇有插图说明的述评 引用了本述评: Novaes Jr. AB, Muglia VA, ramos, Ud, reino dM, Ayub lG. Immediate implants in extraction sockets with periapical lesions: an illustrated review. J osseointegr 2013;5(3):45-52.

Author Athur B. Novaes jr. 1, ValdIir A. MuglIa 3, Umberto d. Ramos 1, Danilo M. ReIno1, Lauro g. Ayub 2 1 巴西圣保罗大学里贝 兰普雷图牙科学院， 口腔与颜面外科学 系、外伤学系和牙周 病学系。 2 巴西RIO GRANDE 天主教大学阿雷格里 港牙科学院临床牙科 学系。 3 巴西圣保罗大学里贝 朗普雷图牙科学院牙 科修复学系l 关键词 骨移植，牙的种植， 即刻种植载入， 尖周病。

摘要 从第一次被提出至今，即刻种植已获得了极大的关注，即刻种植牙替换根尖病变的牙齿是到 今天为止一直被讨论的话题。这次研究的目的是，提供一个配有插图说明的根尖病变牙窝即 刻种植的述评。 材料和方法 我们对MEDLINE/ EMBA的文摘数据库进行了搜索，和文献中介绍的两个配有拔牙窝根尖病 变的即刻种植技术步骤插图的案例。两个案列中的手术部位都有极高的审美要求而且存在相 当规模的牙窝根尖周病变现象。对这两个案例都实施了严格的肉芽组织切除、仔细冲洗拔牙 窝和配合术前康生素的治疗。其次是保证种植牙良好的初期稳定性。 结果和结论 这两个案列的结果都呈现了满意的功能与美学效果。为根尖周病变区进行即刻种植描述了一 个成功的治疗方案。 前言 从发表第一篇关于骨结合这一技术与其第一个 临床试验 (1、2 ) 至今，人们对对骨结合式种植 修复的兴趣已经增长了好多倍。从当初对完全 无牙颌患者的治疗，到后来对部分无牙颌患者 的治疗，再到对单颗牙齿的修复。 传统的骨结合式种植，对拔牙和种植手术时间 的间隔要求是6到8个月。在拔牙后这段长时间 的等待中会发生不可避免的骨遗失，这样的话 植入时就会有骨量不足的问题。骨量不足导致 了需要使用角形植入物或骨移植的办法来解 决。这就导致增加了发病率、疗程的延长和成 本的增加。在种植过程中首先需着重考虑的是 与骨质量和种植部位的深度和宽度，随着诱导 骨再生和骨移植技术的进步，骨量不足所带来 的大部分问题已经解决或大部分已得到解决。 现在主要关注美学效果和软组织增加与稳定性 ( 3、4) 。 因为可以避免拔牙和种植手术间隔时间长所带 来的问题，即刻种植已经得到了人们的重视。 这一技术最早在1976年被提出 (5) ， 此后一直

Fig.1

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成为业界科学讨论的主题。 已经有很多的学者对牙槽嵴水平和成功率之间 的差异做出了评估 ( 6、7) .关于即刻种植术的 成功，人们像报道治疗方案本身时一样的报道 它，并和其他传统方案一样被推荐 ( 7、8、9) , 由于缩短了治疗时间和植入物与假体之间滞后 的问题，即刻种植成了一个很吸引人的治疗方 案。 大多数拔牙原因包括感染区的微生物和炎症引 起的疾病，如牙周炎，或因牙髓感染的根尖 病变。因此，一个越来越感兴趣的问题被提了 出来，如何在一个受感染的区域内进行即刻种 植。这篇配有插图的综述的目标是，查阅现有 的文献资料，并给如何在受感染区域进行即刻 种植提出一个可预测的临床方案，介绍两个经 过12个月跟踪治疗的临床病例。 牙窝根尖周病变即刻种植的文献 所谓的根尖周病变就是由于被感染根管上有病 源菌而引起炎症反应的区域，在组织学检查中 可以发现肉芽组织增生和有密集的嗜中性粒细 胞的炎症渗入到根尖孔的周围，把细菌界定在 Fig.2

根管的根尖部。因此，一些学者认为根尖周病 变对即刻种植的成功存在可预见性的风险，与 这种治疗方案是相悖的 (10至13) 。另一方面， 一些研究者在组织学研究中发现对根尖周病变 牙槽进行即刻种植时呈现出类似非感染区域的 症状 (14) 。

有显著的统计学差异 (16) 。 通过对34个受试者由种植体植入根尖病变部位 和健康部位所取得的临床效果进行对比。种植 体植入1年后结果是，两种治疗方案的结果之 间没有差异。这个研究表明即刻种植体与根尖 周损害牙齿并不相悖 (17)。

首例牙槽根尖周病变即刻种植成功的报告于 1995年发表在Novaes Jr and Novaes上 (15)。 该方案作者提出的建议包括小心的提取和种植 窝的准备(在根尖周病变区用骨凿和刮匙薄薄 的去除所有被感染骨，并诱导出血从而有利于 移植中细胞的增生)之后用丰富的生理盐水溶 液冲洗，到引导骨再生和初次缝合，在离种 植还有24小时时需要做系统性的抗生素治疗方 案。

一项对922列种植手术的回顾性研究( 285个种 植在根尖周感染部位，和637个在健康部位，) 相比两种治疗方案的成功率，结果是成功的定 义为：成功的骨结合修复，没有不被吸收的植 入物。成功率分别为试验组(根尖周感染组)为 97.5%，和对照组(健康组)为98.7%。所以作者 认为在根尖周感染的部位即刻种植是一个安全 可行的治疗方法 (18)。

通过对比在根尖周病变区即刻种植法和延期种 植法。一个前瞻性的随机对照研究报告在2006 年发表了。该调查包括临床和影像指标对从根 尖周病变中提取的样品进行微生物培养和谐振 频率分析的办法来测量种植体的稳定性。作者 的报告显示，即刻种植成功率为92%，延期种 植为100%。两种方案，虽然有个数值差，但没

另一个回顾性研究是对种植物植入感染部位和 植入健康部位后64个月内进行功能测试。最后 对两种治疗方案都报道了类似的成功率，(感 染部位种植的成功率为98.1%,健康部位的种植 成功率为98.2%)(19)。

图1

尖周RX显示右上角 中门牙有严重的根尖 周病变 图2

图2用CT扫描作为诊 断工具进行规划即刻 种植 图3

矢状的CT扫描图显示 低密度绿箭头所指处 和骨长度适合种植棒 的固定。 图4

利用CT扫描制造了三 维模型以用于手术规 划和义齿的制造 图5

拔牙前牙齿临床外观 图6

Fig.5

图6之前的金属瓷冠 在术前被摘除，正面 观。 图7

Fig.3

拔牙前旧义齿被取下 后的咬合视图

Fig.4

图8

Fig.6

Fig.8

用微创拔牙法拔掉患 牙。 图9

有根尖病变的牙齿被 提取出来。 图 10

提取手术后拔牙窝的 咬合视图，手术对临 近软组织的伤害减到 了最小化

Fig.7

Fig.9

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SCIENTIFIC UPDATE

牙窝根尖周变病的即刻种植:一篇有插图说明的述评

病例报告 图 11

取自三维模型的咬合 视图和通过精心设置 的种植棒三维位置 图 12

手术指南视图显示最 佳美学效果的种植棒 位置 图13

植入种植棒后的视图 图 14

保留完整的冠瓣附着 牙龈和软组，这有助 于得到满意的美学效 果。为避免开窗，需 要在厚颊骨顶端进行 移植。

病例1 上门牙右边中间的一颗被指出需要拔除，因为 根据根尖X光片(图1)的显示确诊为严重的根尖 周病变。根据临床特征的需要，我们决定用 即刻种植体支撑种植牙来替代原牙、无翻瓣手 术和即刻临时修复。初诊中所有受损部位都被 记录了下来，并对受损部位进行了刮治和根面 整平，为了得到良好的菌斑控制效果，对口腔 进行了卫生处理。考虑到牙龈的厚度和结构， 用诊断涂蜡法给龈缘位置和APICO冕冠建立 了尺寸。为获得一个三维模型还做了一个锥束 CT扫描(图2和3)。 这时，制定一个手术指南和精确的反向治疗计

划已经有了可能。在制定手术步骤之前，我们 通过对一个三维模型进行外科仿真(图4)来选择 和个性化义体部件并制出一个合适的临时冠。 手术是在局部麻醉状太下进行的，另外，开了 10天用的875毫克阿莫西林处方 ，患者应该在 手术前24小时开始服用。 根据Novaes Jr and Novaes【15】的建议做了无 翻瓣拔牙，拔牙时尽量把创伤减小到最低,拔出 牙齿后仔细清理了拔牙窝创口(图5至10)。用生 理盐水冲洗结束，检查拔牙窝壁，确定前庭壁 合牙窝组织结构适合植入即刻种植棒时，手术 指南就被列出来了(图11和12)。 种植窝的准备已经完成，根据种植棒生产商给 出的指示为一个4.5毫米直径，15毫米长标准的 XiVe S Plus种植体准备了种植窝（XiVe S Plus 种植棒由德国曼海姆Dentsply Implants公司生

图 15

移植物生物活性玻璃 已经放置 图 16

初步缝合已经完成， 临时冠固定完毕

Fig.11

Fig.12

Fig.13

Fig.14

Fig.15

Fig.16

Fig.17

Fig.18

图 17

术后临时冠最终效 果图 图 18

即时手术后的根尖X 光片 图 19

Fig.19

Fig.20

手术1个月后的根尖 X光片

Fig.22

图 20

氧化锆基台种植3个 月后的根尖X光片

Fig.21

Fig.23

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Fig.24

病例2 通过根尖X光片诊断，右侧上切牙由于牙周内 侧病变而需要被拔除（图26）。CT扫描片（图 27）的检查分析显示有结构缺陷的存在，基于 此因，决定对其进行即刻种植和使用临时冠。 在提前服用了一天的康生素后（阿莫西林875 毫克，克拉维酸钾125毫克的组合，每日两 次，连续服用10天，在手术开始前一天开始服 用）拔除了牙齿，提取牙齿后一颗5.5毫米直径 13毫米长的种植棒被固定在离颊骨壁1毫米处 （图28至30）。在同一天，一个4.5毫米直径的 义齿部件被安装好了，然后用旋转基台的办法 放置了临时冠（图31）。9个月后用金属瓷冠 替代了临时冠(图32），12个月后，为了确认治 疗的成功，做了根尖X光片和CT扫描（图33）。

图 21

氧化锆基台的临床颊 侧面 图 22

氧化锆基临床咬合面 图 23

义齿安装6个月后义 齿冠最终外观效果 图 24

手术12个月后的CT扫 描图 图 25

Fig.25

手术12个月后的根尖 X光片 图 26

根尖X光片显示，右 上切牙有严重的根尖 病变 图 27

Fig.26 Fig.27

Fig.28

Fig.29

扫描显示颊骨壁位于 牙根尖部位穿孔 图 28

除之前的牙齿临床 外观 图 29

一片完整的冠瓣被反 褶起，把种植棒定位 在骨嵴顶端正中。 图 30

Fig.30

Fig.31

Fig.32

瓣关闭后手术区临床 外观

Fig.33

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SCIENTIFIC UPDATE

牙窝根尖周变病的即刻种植:一篇有插图说明的述评

讨论

图 31

临时冠入位 图 32

胶固金属瓷冠后的最 终临床效果图 图 33

义齿安装1年后根尖X 光片和CT扫描图

在种植疗法中，为了确保种植的美学和功能效 果，保留牙槽骨的尺寸、牙龈缘位置、牙龈厚 度和牙龈角化组织是非常重要的。因此，为了 减少牙槽突的吸收和减短治疗时间，在新鲜的 拔牙窝内即刻植入种植体被广泛推荐 (7、8、 9、20)。然而，大多数需要拔牙的原因，由牙 齿折裂、牙周炎或牙髓感染引起的。对慢性根 尖周炎感染的区域的即刻种植，并没有达成一 个科学或临床上的共识，它仍然是个有争议的 话题。此外，也没有很多的临床资料可用来参 考。一些临床报告表明，牙髓或牙周发炎史是 一个对导致种植后发炎和种植失败的预测性风 险指标 (21、22、23) 。可以通过靠近种植手术 床附近的软硬组织受到污染来证明这个假说。 这导致了大多数临床医生避免在受感染区域即 刻种植，并认为根尖周感染对即刻种植来说是 一个禁忌 (25)。 另一方面，在慢性感染部位即刻植入种植体有 可能获得成功的结果，而且并不是对所有情形 的禁忌。一个乐观的临床对照研究，比较根尖 病变即刻种植和无根尖病变即刻种植两种治疗 方案的失败率，当手术取得初期稳定时，发 现手术失败指数并没有因为有根尖病变的存 在而增加 (14、15、17)。一个最新的回顾性研 究数据显示，通过对481例根尖周病变的即刻 种植，经过不少于2年的跟踪观察后，发现其 存活率为98.1％，接近于无尖周病变即刻种植 98.2％的存活率 (27)。 Novaes Jr 和 Novaes在1995年提出了一个可以 获得满意结果的治疗方案 (15)，就是通过消除 致病因素和创造有利于组织愈合的条件。为了 得到一个良好的菌斑控制效果，首先，需要对 病人实施口腔卫生措施和刮治与跟面平整。一 个星期后，可以注意到软组织炎症已经减少， 这时在使用抗生素的同时可以进行手术了。抗 生素用法：从手术前24小时时服用第一次，之 后每8个小时一次，连续服用10天 (15)。提倡 用无创无翻瓣拔牙法，拔牙窝必需有4个完整 的壁，接下来还要对其进行清创处理 (14、15) 。要用细致的清创手术去除受污染的软、硬组 织 (15、25)，结合术前与术后的抗生素服用将 为骨愈合及骨结合创造一个有利的条件 (15)。 其他一些必需考虑的因素：骨吸收程度和令人 满意的美学修复效果的种植体角度 (15)。重要 的是，植入物应该放置在最佳审美位置，如果 没有得到这个效果，为了避免将来的审美并发 症，应该考虑诱导骨再生（GBR）。 如果遇到受损害的颊骨壁，为了保证牙槽骨尺 寸的水平，使用诱导性骨再生程序可以建立足 够的审美条件，因为这样可以在种植手术中避 免由于颊壁穿孔而出现灰色区域。然而，在有 可能出现颊骨开窗的情况下可以进行无翻瓣手

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术。要设计一个像本篇所示的根尖诱导骨再生 程序的话，拔牙前一定要 用CT扫描来作为诊 断工具。冠状颊侧壁嵴的保存，有利于牙龈位 置的稳定，可避免出现黑色空间和牙龈萎缩或 种植体基台的暴露；可以带来最佳的美学效 果。根据一个最近的系统性述评，在治疗过程 中进行清创和清洁处理的情况下，曾有根尖病 变的拔牙槽对即刻种植来说并不是一个禁忌。 同一个出版物也报道，虽然对骨移植和系统性 的抗生素应用还有争议，但提倡避免骨再生部 位有可能的术后并发症 (28)。 最近，发表了一个针对美学和影响学结果而 进行了5年的临床对照试验报告 (29)。这项研 究比较了有根尖病变牙窝和无根尖病变牙窝 的即刻种植，两组均接受了诱导性骨再生方案 （GBR）和接受5天的系统性服用康生素（阿 莫西林750毫克）并嘱咐用0.2％的洗必泰冲洗 （没有指出具体的期限）。种植体在安装3个 月后载入。两组所取得的结果并没有评估参数 上的差异。在5年的跟踪研究中，根尖病变牙 窝患者的种植体周围并没有发现任何逆向情况 (29)。 对有持续性急性感染部位是不可以用此治疗方 案的，即时在手术前使用抗生素的情况下，这 种情况下，应该推迟即刻种植计划，直到完成 拔牙，急性感染被得到处理和控制 (25)。对一 个有经验的外科医生而言的，除了对肉芽组织 进行正确清创、避免伤到高贵组织、精确的诱 导骨再生程序、正确的3D植入定位和初期的稳 定性都是影响手术成功的重要因素。

结论 提供的两个病例中所用的治疗方案呈现了一个 圆满的结果，既消除了感染又兼顾了即刻种植 结果良好的功能和美学效果。这可能要归功于 所提出的治疗方案得到了认真细致的执行。

参考文献 1. Branemark PI, Adell r, Breine U, hansson Bo, lindström J, ohlsson A. Intra- osseous anchorage of dental prostheses. I.experimental studies. scand J Plast recons surg 1969;3:81-100.

2. Branemark PI, hansson Bo, Adell r, Breine U, lindström J, hallén o, ohlsson A. osseointegrated implants in the treatment of the edentulous jaw. experience from a 10 year old period. scand J Plast recons surg 1977; 16 (suppl) 3. Tarnow d, elian N, Fletcher P, Froum s, Magner A, cho sc, salama M, salama h, Garber dA.Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol 2003;74:1785-8.

4. degidi M, Novaes AB Jr, Nardi d, Piattelli A. outcome analysis of immediately placed, immediately restored implants in the esthetic area: the clinical relevance of different interimplant distances. J Periodontol 2008;79:1056-61.

5. schulte w, heimke G.The Tubinger immediate implant.

Berlin Quintessenz 1976;27:17–23.

6. degidi M, Nardi d, Piatelli A. Peri-implant Tissue and radiographic Bone levels in the Immediately restored single-Tooth Implant: A retrospective Analysis. J Periodontol 2008;79:252-9.

7. Block Ms, Mercante de, lirette d, Mohamed w, ryser M, castellon P. Prospective evaluation of Immediate and delayed Provisional single Tooth restauration. J oral Maxillofac surg 2009;67(suppl 3):89-107.

8. schwartz-Arad d, Gulayev N, chaushu G. Immediate versus non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth: a retrospective comparative study. J Periodontol 2000;71:923- 8.

9. cornelini r, cangini F, covani U, wilson TG Jr. Immediate restoration of implants placed into fresh extraction sockets for single-tooth replacement: a prospective clinical study. Int J Periodontics restorative dent 2005;25:439-47.

10. schwartz-Arad d, chaushu G.The ways and wherefores of immediate placement of implants into fresh extraction sites: A literature review. J Periodontol 1997;68:915–23.

11. Becker w, Becker Be. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: surgical techniques and case reports.

Int J Periodontics restorative dent 1990;10:377–91.

12. Tolman de, Keller ee. endosseous implant placement immediately following dental extraction and alveoloplasty: Preliminary report with 6-year follow- up.

Int J oral Maxillofac Implants 1991;6:24–8.

13. Barzilay I. Immediate implants: Their current status.

Int J Prosthodont 1993;6:169–75.

15. Novaes AB Jr, Novaes AB. Immediate implants placed into infected sites: a clinical report. Int J oral Maxillofac Implants 1995;10:609-13.

16. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod 2006;6:705-10.

17. siegenthaler dw, Jung re, holderegger c, roos M, hämmerle chF. replacement of teeth exhibiting periapical pathology by immediate implants. A prospective controlled clinical trial. clin oral Impl res 2007;18:72737.

18. Bell cl, diehl d, Bell BM, Bell re. The immediate placement of dental implant into extraction sites with periapical lesions: A retrospective chart review. J oral Maxillofac surg 2011;69:1623-7.

19. Fugazzotto PA, A retrospective Analysis of Implants Immediately Placed in sites with and without Periapical Pathology in 64 Patients. J Periodontol 2011 [ahead of print].

20. lazzara rJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics restorative dent 1989;9:332-43.

21. Ayangco l, sheridan PJ. development and treatment of retrograde peri-implantitis involving a site with a history of failed endodontic and apicoectomy procedures: a series of reports. Int J oral Maxillofac Implants 2001;16:412-7.

22. oh TJ, yoon J, wang hl. Management of the implant periapical lesion: a case report. Implant dent 2003;12:41-6.

23. Karoussis IK, salvi Ge, heitz-Mayfield lJ, Brägger U, hämmerle ch, lang NP. long-term implant prognosis in patients with and without a history of chronic periodontitis: a 10-year prospective cohort study of the ITI dental Implant system. clin oral Implants res 2003;14:329-39.

24. Polizzi G, Grunder U, Goené r, hatano N, henry P, Jackson wJ, et al.. Immediate and delayed implant placement into extraction sockets: a 5-year report. clin Implant dent relat res 2000;2:93- 9.

25. casap N, Zeltser c, wexler A,Tarazi e, Zeltser r. Immediate placement of dental implants into debrided infected dentoalveolar sockets. J oral Maxillofac surg 2007;65:384-92.

26. Fugazotto P. A retrospective analysis of Immediately Placed Implants in 418 sites exhibiting periapical pathology: results and clinical considerations. Int J oral Maxillofacial Impl 2012; 27:194-202.

27. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod. 2006;101:705-10.

28. waasdorp JA, evian cI, Mandracchia M. Immediate Placement of Implants into Infected sites: A systematic review. J Periodontol 2010;81:801-8.

14. Novaes AB Jr, Vidigal GM Jr, Novaes AB, Grisi MFM, Polloni s, rosa A. Immediate implants placed into infected sites: A histomorphometric study in dogs. Int J oral Maxillofac Implants 1998;13:422–72

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SCIENTIFIC UPDATE Immediate implants in extraction sockets with periapical lesions: an illustrated review

Immediate implants in extraction sockets with periapical lesions: an illustrated review TO CITE IN THIS ARTICLE: Novaes Jr. AB, Muglia VA, ramos, Ud, reino dM, Ayub lG. Immediate implants in extraction sockets with periapical lesions: an illustrated review. J osseointegr 2013;5(3):45-52.

Author Athur B. Novaes jr. 1, ValdIir A. MuglIa 3, Umberto d. Ramos 1, Danilo M. ReIno1, Lauro g. Ayub 2 1 department of Bucco-Maxillo-Facial surgery and Traumatology and Periodontology, school of dentistry of ribeirao Preto, University of sao Paulo, ribeirão Preto, SP, Brazil 2 department of clinical dentistry, school of dentistry, Pontifical catholic University of rio Grande do sul, Porto Alegre, rs, Brazil Rio Grande 3 department of Prosthetic dentistry, school of dentistry of ribeirao Preto, University of sao Paulo, ribeirão Preto, SP, Brazil KEY WORDS

Bone grafting; dental implants; Immediate implant loading; Periapical disease.

ABSTRACT

Aim: Immediate implantation has gained great attention since first proposed. Immediate implants in replacement of teeth with periapical lesion is, to date, an issue of discussion. The aim of this study is to perform an illustrated literature review of immediate implants in sockets exhibiting previous periapical lesions.

Materials and methods: A search on medline/eMBAse database was done for the literature review which is presented together with two case reports illustrating the state of the art of immediate implants on sockets with periapical lesions. Both cases are presented in areas with great aesthetic demands and a periapical lesion of considerable size. The two cases were conducted following strict granulation tissue removal and careful rinsing and pre-operative antibiotics, followed by good primary stability of the dental implant.

Results and conclusion: Both cases represented successes in aesthetics and function, describing a successful protocol for immediate implant installation in areas exhibiting periapical lesions.

INTRODUCTION Since the publication of the first papers describing the phenomenon of osseointegration and the very first clinical trials (1, 2), the interest on osseointegrated implant rehabilitation has grown exponentially. At first, for the treatment of totally edentulous patients, posteriorly for partially edentulous and single unit implants.

The classic protocol for the treatment with osseointegrated implants recommended 6 to 8 month between tooth extraction and implantation. This long waiting period is associated with an unavoidable bone loss that occurs after tooth extraction, which may lead to difficulties such as insufficient bone at the time of implantation. The insufficient bone leads to the use of angulated implants or the need of bone grafting procedures, increasing the morbidity, the treatment chair time and costs. At first, the main concern was with bone quality, and with the length and width of the site of implantation. With the advances on guided bone regeneration and grafting procedures, most of the problems related to the amount of bone has been solved or mostly solved, now the focus is mainly on aesthetics and amount of soft tissue increase or stability (3, 4). Immediate implantation has gained attention

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Fig.2

in order to avoid the problems related to the time lag between extraction and implant placement. The difference between crestal bone level and success rate has been evaluated by a number of authors (6,7). The success of immediate implants has been reported as similar to delayed implantation, as suggested by the original protocol (7, 8, 9), becoming an attractive treatment protocol to reduce treatment time and the lag between implantations and the prosthesis.

Most of the reasons for tooth extraction include infected areas as a result of microbial and inflammatory diseases, such as periodontal disease, or periapical lesions from endodontic infections. Thus, an increasing interest has been shown on how immediate implantation would perform in infected sites. This illustrated review has the objective of reviewing current literature and to propose a predictable clinical protocol for immediate implantation on infected sites, presenting two clinical cases with 12 months of follow up.

Literature on immediate implant placement in AlveolI with periapical lesions Periapical lesions are known as areas of inflammatory reaction due to the presence of pathologic agents on

an infected root canal. On histologic examination it is possible to notice the presence of granulation tissue and inflammation with a dense neutrophil infiltrate near the apical foramen delimiting the bacteria on the apical part of the root canal.Thus, a number of authors consider the presence of periapical lesions a risk to the predictability of immediate implant success, contraindicating this treatment protocol (10-13). On the other hand, some authors showed, on histological studies, that immediate implantation in sockets with periapical lesions presented similar results to non-infected sites (14). The first report of success on immediate implantation in sockets with periapical lesions was described

by Novaes Jr and Novaes in 1995 (15). The protocol suggested by the authors included careful extraction and debridation of the socket (removing a thin layer of bone from hte periapical lesion area with chisels and curettes to remove any infected bone and to induce bleeding, thus favoring cell population of the graft) followed by copious irrigation with saline solution, by guided bone regeneration, primary closure and a systemic antibiotic regimen, starting 24 hours before implantation. A prospective randomized study comparing the placement of immediate implants in sites with previous periapical lesions with delayed implantation was published in 2006. The investigation included clinical and radiographic parameters, microbiological culture from samples collected from periapical lesions and Resonance Frequency Analysis (RFA) measuring

implant stability. The authors reported a success rate of 92% for immediate implants and 100 % for delayed implant placement. Although there was a numerical difference, there was no significant statistical difference (16). A study with 34 subjects compared the clinical results achieved by implant placement in periapical lesion sites and healthy sites. One year after the implant placement, there was no difference between the treatment protocols. This study showed that immediate implant placement in periapically compromised teeth is not contraindicated (17).

A retrospective study with 922 implants (285 placed in periapical infected sites and 637 in healthy sites) compared the success rate on both treatment protocols: success was defined as successful osseointegration, restoration and absence of periimplantitis.

Success rates were 97.5% for the test group (periapical infection group) and 98.7% for the control group (healthy group). Therefore, the authors considered the placement of immediate implants in periapically infected sites a safe and a viable treatment protocol (18).

Another retrospective study comparing implant placement into infected sockets and on pristine sites with a mean time of function of 64 months reported a similar success rate (98.1% for infected sites and 98.2% for pristine sites) for both treatment protocols (19).

Fig. 1 Periapical rx showing extensive periapical lesion on the upper right central incisor.

Fig. 2 A cT scan was used as a diagnostic tool to plan the immediate implant..

Fig. 3 cT can with the sagittal view showing the hypodensity (green arrow) and the bone height available for implant anchorage.

Fig. 4 Three dimensional model fabricated from the cT scan and the surgical and prosthetic planning Fig.5 clinical aspect of the tooth before extraction.

Fig.5

Fig.6 The pre-existent metalloceramic crown was removed before extraction.

Frontal view.

Fig.3

Fig.4

Fig.6

Fig.8

Fig.7 occlusal view of the tooth without the prosthesis, before extraction.

Fig.8 Tooth extraction with the periotome, minimally invasive approach.

Fig.9 Tooth extracted with the periapical lesion attached.

Fig.7

Fig.10 occlusal aspect of the socket after tooth extraction. There was minimal surgical damage to adjacent soft tissue

Fig.9

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SCIENTIFIC UPDATE Immediate implants in extraction sockets with periapical lesions: an illustrated review

Fig. 11 occlusal view from the 3d model and the tridimensional position of the implant carefully planned.

Fig. 12 occlusal view of the surgical guide showing the optimal prosthetic position for the implant.

Fig. 13 occlusal view of the implant after insertion.

Fig. 14 The full flap preserving corona The full flap preserving coronal attached gingiva, soft tissues and aesthetics. Thick buccal bone on the apical aspect required a graft to avoid fenestration.

Fig.15 Graft (bioactive glass) in position.

CASE REPORT Case 1 The upper right central incisor was indicated for extraction due to an extensive periapical lesion diagnosed from periapical radiographs (Fig. 1). Due to favorable clinical characteristics, tooth replacement with an immediate implant-supported crown, flapless surgery and immediate provisionalization was planned.

On the first visit all compromised sites were recorded and a scaling and root planning was performed. Oral hygiene instructions were given in order to perform excellent plaque control. The gingival marginal position and apico-coronal crown dimensions were established with a diagnostic waxing, considering gingival thickness and architecture. A Cone Beam CT scan was performed in order to obtain a tridimensional model (Fig. 2, 3). Thus, it was possible to fabricate a surgical guide and a precise reverse treatment planning. A surgical simulation (Fig. 4) on the 3D model to choose and individualize the prosthetic component and the

confection of a provisional crown before the surgical phase was made. The surgical phase was performed with local anesthesia and the prescription of Amoxicillin 875 mg for 10 days, starting 24 hours before the surgical procedure.

Flapless tooth extraction, with the least amount of trauma as possible, was performed and the socket was carefully debrided as suggested by Novaes Jr and Novaes (15) (Fig. 5-10).

After irrigation with saline solution the socket walls were inspected and the vestibular wall and socket morphology were considered suitable for immediate implant insertion. The surgical guide was placed (Fig. 11, 12) and the protocol for socket preparation was performed, in accordance to the manufacturer’s instruction, for a 4.5 mm diameter and 15 mm length implant (XiVe S Plus, Dentsply Implants, Mannheim, Germany). The implant was placed 1 to 1.5 mm from

Fig.11

Fig.12

Fig.13

Fig.14

Fig.15

Fig.16

Fig.17

Fig.18

Fig.16 Primary closure achieved and provisional crown in position.

Fig.17 Final aspect of the provisional crown after surgery.

Fig.19

Fig.20 Fig.22

Fig.18 Periapical radiograph on the immediate post-operative period.

Fig.19 Periapical radiograph taken 1 month after surgery.

Fig.20 Periapical radiograph taken 3 months after surgery with the zirconia abutment.

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Fig.21

Fig.23

Fig.24

the buccal bone wall and anchored on the nasal cavity floor to obtain primary stability (Fig. 13).

Although the coronal alveolar wall was in good condiditon, the apical portion was too thin, due to the periapical lesion, and a grafting material (Biogran, Biomet 3i, Palm Beach, FL- USA) was placed with an apical access (Fig. 14, 15). A provisional crown was placed after the implant and grafting procedures.

A zirconia abutment (Cercon, Dentsply Implants, Mannheim, Germany) was connected to the implant and a metal-free ceramic crown was cemented (Fig. 16-18). At 1 and 3 months post-operatively, a periapical radiograph was performed (Fig. 19, 20), and clinical photos were taken (Fig. 21, 22). During this period the left central incisor was lost due to trauma.

After 6 and 12 months a CT scan was made to ensure treatment success and resolution of the periapical lesion (Fig. 23-25).

Case 2 The upper right incisor was indicated for extraction due to an endo-perio lesion diagnosed by periapical radiographs (Fig. 26). Based on defect configuration, analyzed by a CT scan examination (Fig. 27), an immediate implant with an immediate provisional crown was planned.

The tooth was extracted with a previous antibiotic prescription (Amoxicillin 875 mg-Potassium Clavulanate 125 mg combination, twice daily, for ten days, starting one day before the procedure). After tooth extraction a 5.5 mm diameter and 13 mm length implant (XiVe S Plus, Dentsply Friadent, Mannheim, Germany) was inserted 1 mm apically to palatal bone wall (Fig. 28-30). On the same day, a 4.5 mm diameter prosthetic component was installed and a provisional crown was placed, performing a platform switching strategy (Fig. 31). After 9 months, a metalloceramic

Fig.25

Fig. 21 Periapical rx showing clinical buccal aspect of the zirconia abutment.

Fig. 22 clinical occlusal aspect of the zirconia abutment.

Fig. 23 Final aspect of the prosthetic crown 6 months after prosthesis installation.

Fig. 24 cT scan 12 months after surgery.

Fig.25 Periapical radiograph 12 months after surgery.

Fig.26 Fig.27

Fig.28

Fig.29

Fig.26 Periapical radiograph showing extensive periapical lesion on the upper right incisor.

Fig.27 cT scan showing buccal bone wall fenestration on apical aspect of the tooth.

Fig.28 clinical aspect of the tooth before extraction.

Fig.30

Fig.31

Fig.29 A full flap was reflected.

Implant was positioned subcrestaly to the bone crest.

Fig.30 clinical aspect of the surgical area after flap closure.

Fig.32

Fig.33

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SCIENTIFIC UPDATE Immediate implants in extraction sockets with periapical lesions: an illustrated review crown was placed (Fig. 32). At 12 months, a control periapical radiograph and CT scan was requested (Fig. 33), confirming the treatment success.

Fig. 31 Provisional crown in place.

Fig. 32 Final clinical aspect after the metalloceramic crown was cemented.

Fig. 33 Periapical radiograph and cT scan of the area 1 year after prosthesization

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DISCUSSION In order to maintain aesthetic and functional conditions with implant therapy, it is important to preserve alveolar bone dimensions, gingival margin position, gingival thickness and keratinized gingival tissue. Thus, aiming to reduce alveolar process resorption and treatment time, immediate implant placement in fresh extraction sockets has been largely proposed (7, 8, 9,2 0). However, most of the reasons for tooth extraction include infected areas caused by tooth fracture, periodontitis or endodontic infection. It is still controversial and there is no scientific or clinical consensus about the immediate implant indication in areas of chronic periapical infected sites, in addition, few clinical data are available. Some clinical reports have suggested that history of endodontic or periodontal infections is a predictive risk marker for future implant infection and failure (21, 22, 23). This hypothesis may be justified by the possibility of soft and hard tissue contamination located near the implant surgical bed. This led most clinicians to avoid immediate placement of dental implants at infected sites and to consider periapical infection a contraindication for immediate implantation (25).

On the other hand, placement of immediate implant in chronically infected sites may have successful outcomes and is not a contraindication in all cases. A prospective controlled clinical study comparing immediate implants in sites with or without periapical lesions failed to achieve differences between the two protocols.

The failure index did not increase in the presence of periapical lesions when the implant achieved primary stability (14, 15, 17). More recent data of a retrospective study (418 implants placed in sockets with periapical lesions) with a minimum of 2 years follow up showed a survival rate (98.1%) similar to implants placed on pristine sites (98.2%) (27).

A protocol option to achieve a successful outcome was proposed by Novaes Jr and Novaes in 1995 (15) ,consisting in the elimination of the etiological factors and to create favorable conditions for tissue healing.

In the first step the patient must receive oral hygiene instructions and scaling and root planing in order to perform good plaque control. After one week, a reduction of soft tissue inflammation can be noted and the surgery in association with the use of antibiotics (for 10 days, every 8 hours, starting 24 hours before surgical procedure) (15) can be performed. Atraumatic flapless tooth extraction is encouraged, and the socket must have 4 intact walls and in sequence should be carefully debrided (14, 15). The contaminated soft and hard tissues removal by meticulous debridement (15, 25), combined with pre- and postoperative antibiotics will establish a favorable basis for bone healing and osseointegration (15). Some other factors must be considered: the extent of bone resorption and the angle of the implant for a satisfactory aesthetic re-

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storation (15). The implant should be placed in the optimal aesthetic position, if not, the procedure should be delayed and a GBR should be considered in order to avoid future aesthetic complications. In case of compromised buccal bone walls, in order to preserve horizontal alveolar bone dimensions, association of Guided Bone Regeneration procedures can create adequate aesthetic conditions avoiding visualization of a gray band, from the implant, due to buccal wall fenestration. However, it is possible to perform a flapless approach in cases in wich the buccal bone fenestration is expected. Planning a GBR procedure with an apical approach, as shown in this paper, is only possible with a CT scan as a diagnostic tool before tooth extraction. The preservation of the coronal buccal wall crest will permit stability of the gingival position, avoiding black spaces and gingival recession or implant abutment exposure, giving an optimal aesthetic result.

According to a recent systematic review, immediate implant placement into sockets with previous periapical pathology is not contraindicated when a protocol of systematic debridement and cleaning is performed. The same publication reported that the use of bone graft and the use of systemic antibiotics, although controversial, is encouraged to avoid possible post- operative complications at the regenerated site (28). More recently, a controlled clinical trial with aesthetic and radiographical outcomes after 5 years was published (29). This study compared immediate implants placed in sockets exhibiting previous periapical lesions (n=11) with sockets without this condition (n=15), both groups received GBR concomitant to implant installation and received 5 days of systemic antibiotics (Amoxicillin 750 mg) and were instructed to rinse with chlorhexidine 0.2% (period not informed).

The implants were loaded 3 months after installation.

The results achieved did not demonstrate differences between both groups on the parameters evaluated.

None of the immediate implants installed in sites with previous periapical lesions exhibited retrograde periimplantitis during the 5 years of follow up (29). This protocol cannot be used in cases where an acute infection persists even when the pre-surgical antibiotic is used, the immediate implant placement should be postponed, the tooth removed and the acute infection treated (25). It is indicated for experienced surgeons since the correct debridement of the granulation tissue, avoiding violation of noble tissues, accurate guided bone regeneration procedures, correct 3D implant positioning and primary stability are important factors for treatment success.

CONCLUSION The proposed protocol used in the two cases reported, presented a successful outcome, achieving elimination of the infection and immediate dental implant placement with good functional and aesthetic outcomes. This is possible thanks to a meticulous execution of the proposed treatment protocol..

REFERENCES 1. Branemark PI, Adell r, Breine U, hansson Bo, lindström J, ohlsson A. Intra- osseous anchorage of dental prostheses. I.experimental studies. scand J Plast recons surg 1969;3:81-100.

2. Branemark PI, hansson Bo, Adell r, Breine U, lindström J, hallén o, ohlsson A. osseointegrated implants in the treatment of the edentulous jaw. experience from a 10 year old period. scand J Plast recons surg 1977; 16 (suppl) 3. Tarnow d, elian N, Fletcher P, Froum s, Magner A, cho sc, salama M, salama h, Garber dA.Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol 2003;74:1785-8.

4. degidi M, Novaes AB Jr, Nardi d, Piattelli A. outcome analysis of immediately placed, immediately restored implants in the esthetic area: the clinical relevance of different interimplant distances. J Periodontol 2008;79:1056-61.

5. schulte w, heimke G.The Tubinger immediate implant.

Berlin Quintessenz 1976;27:17–23.

6. degidi M, Nardi d, Piatelli A. Peri-implant Tissue and radiographic Bone levels in the Immediately restored single-Tooth Implant: A retrospective Analysis. J Periodontol 2008;79:252-9.

7. Block Ms, Mercante de, lirette d, Mohamed w, ryser M, castellon P. Prospective evaluation of Immediate and delayed Provisional single Tooth restauration.

J oral Maxillofac surg 2009;67(suppl 3):89-107.

8. schwartz-Arad d, Gulayev N, chaushu G. Immediate versus non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth: a retrospective comparative study. J Periodontol 2000;71:923- 8.

9. cornelini r, cangini F, covani U, wilson TG Jr. Immediate restoration of implants placed into fresh extraction sockets for single-tooth replacement: a prospective clinical study. Int J Periodontics restorative dent 2005;25:439-47.

10. schwartz-Arad d, chaushu G.The ways and wherefores of immediate placement of implants into fresh extraction sites: A literature review. J Periodontol 1997;68:915–23.

11. Becker w, Becker Be. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: surgical techniques and case reports.

Int J Periodontics restorative dent 1990;10:377–91.

12. Tolman de, Keller ee. endosseous implant placement immediately following dental extraction and alveoloplasty: Preliminary report with 6-year follow- up.

Int J oral Maxillofac Implants 1991;6:24–8.

13. Barzilay I. Immediate implants: Their current status.

Int J Prosthodont 1993;6:169–75.

14. Novaes AB Jr, Vidigal GM Jr, Novaes AB, Grisi MFM, Polloni s, rosa A. Immediate implants placed into infected sites: A histomorphometric study in dogs. Int J oral Maxillofac Implants 1998;13:422–72 15. Novaes AB Jr, Novaes AB. Immediate implants

placed into infected sites: a clinical report. Int J oral Maxillofac Implants 1995;10:609-13.

16. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod 2006;6:705-10.

17. siegenthaler dw, Jung re, holderegger c, roos M, hämmerle chF. replacement of teeth exhibiting periapical pathology by immediate implants. A prospective controlled clinical trial. clin oral Impl res 2007;18:72737.

18. Bell cl, diehl d, Bell BM, Bell re. The immediate placement of dental implant into extraction sites with periapical lesions: A retrospective chart review. J oral Maxillofac surg 2011;69:1623-7.

19. Fugazzotto PA, A retrospective Analysis of Implants Immediately Placed in sites with and without Periapical Pathology in 64 Patients. J Periodontol 2011 [ahead of print].

20. lazzara rJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics restorative dent 1989;9:332-43.

21. Ayangco l, sheridan PJ. development and treatment of retrograde peri-implantitis involving a site with a history of failed endodontic and apicoectomy procedures: a series of reports. Int J oral Maxillofac Implants 2001;16:412-7.

22. oh TJ, yoon J, wang hl. Management of the implant periapical lesion: a case report. Implant dent 2003;12:41-6.

23. Karoussis IK, salvi Ge, heitz-Mayfield lJ, Brägger U, hämmerle ch, lang NP. long-term implant prognosis in patients with and without a history of chronic periodontitis: a 10-year prospective cohort study of the ITI dental Implant system. clin oral Implants res 2003;14:329-39.

24. Polizzi G, Grunder U, Goené r, hatano N, henry P, Jackson wJ, et al.. Immediate and delayed implant placement into extraction sockets: a 5-year report. clin Implant dent relat res 2000;2:93- 9.

25. casap N, Zeltser c, wexler A,Tarazi e, Zeltser r. Immediate placement of dental implants into debrided infected dentoalveolar sockets. J oral Maxillofac surg 2007;65:384-92.

26. Fugazotto P. A retrospective analysis of Immediately Placed Implants in 418 sites exhibiting periapical pathology: results and clinical considerations. Int J oral Maxillofacial Impl 2012; 27:194-202.

27. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod. 2006;101:705-10.

28. waasdorp JA, evian cI, Mandracchia M. Immediate Placement of Implants into Infected sites: A systematic review. J Periodontol 2010;81:801-8.

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阻生弯曲上切牙正畸中的直丝弓矫治器 定位技巧 文章来源: Celli D, Greco AL, Sferra S, Deli R. Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance. Eur J Paediatr Dent 2015; 16(3): 191-196.

摘要

目的：描述由于前乳牙创伤而引起的上颌切牙阻生弯曲的正畸操作方案，展示上中切牙 牙根弯曲的临床操作，叙述如何通过合适的多学科方法用一个最简单而有效的直丝弓技术把 一个年幼患者的弯曲牙成功地移到对齐于牙列的位置。 病例报告 通过手术暴露和正畸牵引后，阻生弯曲牙移到于牙列排齐。患者的咀嚼功能、说话功能和 美观度均得到恢复，X光片显示，牙根最后变直并相对得到发育。这个方法避免了弯曲牙的拔 除和假体修复。 引言 Andreasen等学者在[1971]年给弯曲牙下了一 个定义：弯曲牙就是牙齿的牙冠长轴与牙根比 例有严重偏差，这是由于已经形成的硬体组织 相对于发育中的软组织有一个创伤性非轴向移 位而造成的。 在急诊中，知道在何时、何地、如何造成创 伤对于做出一个精确的诊断是非常重要，如此 才可以采用正确的最有效的临床步骤。[Ribeiro 和 Campos在 2009年提出]。 目前还尚未完全理解弯曲牙的病因，现在有 两种主流的解释;由于乳牙受到急性机械性创伤 而导致下层正在发育的恒压变弯曲；特发性发 育障碍引起的牙弯曲，这种情况，一般均在没 有明显的创伤痕迹和创伤史的病例中[Topouzelis 等在2010年报道; Smith 和Winter在 1981年报 道; Jafarzadeb 和Abbott也在2007年报道; Stewart 在1978年报道]。 弯曲牙的治疗程序包括手术暴露和之后的正 畸牵引，还可能有配合性的根管治疗和根尖切 除术 [Lin,在1999年提出]。其他的治疗方案经常 包括外科手术摘除，之后进行正畸治疗来闭合 空间，或者保留空间一直等到患者可以接受种 植或假体治疗的年龄。 本文介绍了如何把一个多学科方法的操作流 程用在一个有弯曲上中切牙的患者上。通过运 用一个简单而有效的直丝弓矫治器定位技巧， 在实验的结果，弯曲牙已被去除阻力，并最终 被排齐。 病例报告 诊断和治疗方案 一个9岁的白人女孩被她的牙医推荐给我们的 试验，患者主要症状是上右中切牙阻生，她的 父母提到，孩子在5岁的时候有过一次跌打性 损伤擦伤了她的前额口腔区域。

临床检查显示患者有对称的颅面部。 口腔检查显示有早期的牙列混合不齐，犬牙 和磨牙之间形成一个I类角。右上中切牙的阻 生导致其远离了邻近牙，最终出现中线偏差 （图1）。1.1牙区的牙龈组织上有根金属链， 因为她的牙医已经给她进行了手术暴露并放置 了一根牵引链。我们给患者做了X咬合线片， 结果显示有一个支架和阻生牙的颚面粘合在一 起（图2）。 前庭黏膜的触诊显示，在上前方有个隆起的 部位，很有可能就是阻生牙所在位置。根据X 头影、全景X光片和咬合面结果发现，上颌右 侧中切恒牙阻生并显示牙根弯曲。根尖孔显示 有一个圆形区域，在该圆形区域的中心还有一 个可透射暗斑，该暗斑被称为“靶心”。外侧牙 齿的位置和形态清晰可见，头部测量的X线片 显示了一颗平躺的牙齿，牙冠从正常牙冠的位 置旋转了100°，牙尖就在鼻腔基下方(图3)。 牙冠的颚面朝向前方，就像交通指挥警察的手 一样，牙根缩短；因此不可能精确地在X成像 上确定根尖。 X头影的侧面分析显示一副II型闭塞骨架和均 衡的面型（表1）。 治疗的目标是引导阻生牙到正确地于邻近的 牙对齐，并重新打造一个完整的前牙。治疗的 目的是在维持阻生牙牙根的活力和完整性的前 提下避免牙根进一步受损，并实现对牙冠和牙 根的正确定位。治疗的目标还有，挤压其所有 的周围组织（牙槽骨和附着龈），并评估牙龈 和牙周的长期状况。 这是一个综合了多个学科的治疗方法，是个 外科手术和正畸治疗的结合。

Author D. Celli.

A. L. Grego, S. Sferra, R. Deli 意大利罗马圣心天主 教大学

e-mail: simonesferra @hotmail.it 关键词：弯曲牙； 直丝弓矫治器；阻 生上中切牙。

治疗过程 为了给阻生中切牙疼出空间，我们在上颌恒 牙上固定了一个STEP（由意大利佛罗伦萨的 DoctorOs 牙医 Infodent International •3/2017

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SCIENTIFIC UPDATE

阻生弯曲上切牙正畸中的直丝弓矫治器定位技巧

Fig.1d

图 1(a-i)

Fig.1e

治疗前口内和口外 照片。 图 2(a-b)

治疗前的全景和上 颌咬合X线片。

Fig.1a

Fig.1b

Fig.1c

Fig.1f

Fig.1g

Fig.1h

图 3a

治疗前的X线投影 显示弯曲的上切 牙。 图 3b Celophametric tracing Table 1 Cephalometric data.

Leone公司生产）直丝弓矫治器(图4). 用预制的Ni-Ti 0.014 和 0.016英寸的弓丝来调 整和整平上颌前牙。然后，一个开放式的螺旋 弹簧被固定在2.1号牙 和 1.2号牙之间的0.018英 寸澳大利亚弓丝上，以便于在弓内给弯曲牙打 开足够的空间。 获得足够的空间后，阻生牙亦开始长出，手术 计划已经完成。上颌中切恒牙手术暴露后接着 进行顶端折翼重新定位，如此，在唇齿面上可 以粘贴一个按钮。唇面上的按钮可以使牙冠颚 更好的运动（图5）。 通过连接牵引链和弓丝完成了右上中切恒牙 的正畸牵引。 之后，用0.020英寸的澳大利亚弓丝与挤压轴 上的小孔来垂直咬合并继续进行排齐和整平；

Fig.2a

Fig.2b

Fig.3a

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DoctorOs 牙医 Infodent International •3/2017

Fig.3b

Fig.1i

通过每2周更换一次弹力棉线，牵引被激活， 直到上颌中切恒牙牙冠在口腔的正确位置上为 止。牵引力大约40克，这个治疗阶段持续了6 个月（图6）。 接下来，从上颌右中切恒牙的唇面移除了按 钮，并粘合了一个支架。预制的Ni–Ti 0.014 和0.016英寸的圆弓丝被用在上牙上。 与此同时，在下颌恒牙上放置了一个直丝弓 矫治器。 之后的整个上颌右中切牙排齐过程都用 0.018 和0.020 英寸的澳大利亚弓丝。 右中切牙被调整到里中切线更近的地方，一个 正畸支架被倒置在弯曲牙的唇面上，用一根 Ni-Ti 0.019 x 0.025的弓丝来启动唇根扭矩。这 种战略性的支架定位可以保证两颗中切牙更好

SNA SNB ANB Wits appraisal SN/Go-Gn FMA SN/ANS-PNS ANS-PNS / Go-Gn +1 / ANS-PNS IMPA -1 / A-Pg +1 / A-Pg OVJ OVB

Pre-treatment 81 76,5 5,5 2 34 26 8 22 112 102 2 8 5 4

Post-treatment 82 78 4 0 37 28 14 23 118 96 2 4 2 2

图 4(a-f)

Fig.4a

Fig.4b

术前口内视图。

Fig.4c

图 5(a-b)

阻生牙的手术暴 露。 图 6(a-f)

Fig.4d Fig.4d

正畸牵引的进度。 Fig.4e

的牙根位置和协调的龈缘（图7）。 用一根带有一个系带的 0.019 x 0.025英寸的不 锈钢丝继续治疗，约3个月后，1.1齿上的支架 被放正。最后一步用的是 0.018英寸的澳大利 亚弓丝。 治疗结果 治疗26个月后，支架被摘除，恒牙被粘合 在下前牙的靠舌面上。在治疗结束时，独立 的已连接的弯曲牙牙龈似乎到了可以接受的程 度(图8)。阻生弯曲牙已经被适当地排齐在牙 列中，恢复了患者的咀嚼、发音和审美功能。 从X光线角度来讲，牙根最终被排齐并且没有 受到严重的损害（图9至11）。患者后来被转 至原来的牙医处进行切缘恢复。为期一年的

Fig.4f

随访发现维持了良好的手术结果。在成年后， 患者有可能需要接受牙周审美手术和修复治疗 (图12)。 讨论 如这项研究一样，很多关于弯曲牙的研究中 提到了上颌中切牙。 McNamara 等用一个综合了根管治疗和根 尖切除术的治疗方法，在 [1998]年成功地排齐 了弯曲的上颌中切牙。通过一个适当的治疗方 案，阻生弯曲牙可以被排齐在牙列中，这往往 需要正畸医生、牙周医生、牙髓医生和假牙医 生之间的合作。不同于一些其他类似的案例， 在本次实验中没有必要进行牙髓治疗和根尖切 除术。

Fig.5b

Fig.5a

Fig.6a

Fig.6b

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SCIENTIFIC UPDATE

图 7(a-d)

阻生弯曲上切牙正畸中的直丝弓矫治器定位技巧

Fig.7a

Fig.7c

Fig.7b

Fig.7d

弯曲牙被认为比正常牙根的牙更耐挤压，使得 心尖区更容易再吸收。但总的来说并没有发现 明显的严重的牙根再吸收，需要强调一点，在 弯曲牙中，牙根再吸收现象很难被预测。正畸 牵引期间最好进行X光线检查 [Cozza 等在 2005 年提出]。 影响一个阻生弯曲牙的排齐成功率的因素有 如下几种; - 阻生牙的位置和朝向 - 牙根的形成程度； - 弯曲程度； - 阻生牙的可用空间。 Machtei 等 [1990年的报告中]则认为应该还包 括牙周组织的条件，McNamara 等[在1998年的 报告中]却强调了牙根外部Hertwig外皮细胞的

伤后条件对一个成功的治疗结果有关键性的作 用，因为正常牙根的发育取决于它的完整性。 在正畸牵引中，一个钝角倾斜而且位置低于牙 槽嵴却有完整成形牙根的弯曲牙会有一个更好 的预知结果。

结论 决定能否取得一个良好结果的因素如下; 战略性定位直丝弓矫治器可以正确定位牙 根，并且使两颗中切牙的龈缘有较好的协调 性。 按钮放置在唇面上可以使牙冠颚运动不被 限制。 通过牵引链、弹力棉线和超弹性NiTi丝发 挥的作用而施加柔和恒定的矫治力(40克)。

支架倒装固定战略 定位。 图 8(a-o)

剥离后的记录。

Fig.8e

Fig.8a

Fig.8b

Fig.8f

Fig.8g

Fig.8c

Fig.8d

Fig.8h Fig.8o

Fig.8i

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Fig.8l

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Fig.8m Fig.8n

图9

Fig.9

Fig.10a

参考文献 › Andreasen JO, Sndström B, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors.

A clinical and histologic study of 117 injured permanent teeth. Scand J Dent Res 1971 ; 79:219–83. › Cozza P, Marino A, Condo, R. Orthodontic treatment of an impacted dilacerated maxillary incisor: a case report. J Clin Pediatr Dent Winter 2005 ; 30(2):93-7, . › Jafarzadeb H, Abbott P. Dilaceration: review of an endodontic challenge. J Endod 2007 ; 33:1025–30. › Lin YTJ. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999 ; 115:406–9. › Machtei EE, Zyskind K, Ben-Yehouda A. Periodontal considerations in the treatment of dilacerated maxillary incisors. Quintessence Int 1990; May 21(5):357-60. › McNamara T, Woolfe SN, McNamara CM. Orthodontic management of a dilacerated maxillary central incisor

Fig.10b

治疗后的全景X线 片显示被排齐的上 中切牙根没有再吸 收现象。

Fig.11

with an unusual sequel. J Clin Orthod 1998; 32:293–7. › Ribeiro D, Campos V. Prevalence of sequelae in the permanent anterior teeth after trauma in their predecessors: a longitudinal study of 8 years. Dental Traumatology 2009 ; 25:300–304. › Stewart DJ. Dilacerate unerupted maxillary central incisors. Br Dent J 1978 145: 229–33. › Smith DMH, Winter GB. Root dilaceration of maxillary incisors. Br Dent J 1981; 150:125–7. › Topouzelis N, Tsaousoglou P, Pisoka V, Zouloumis L. Dilaceration of maxillary central incisor: a literature review.

Dental Traumatology 2010; 26:427–433. › White SC, Pharoah MJ, Oral radiology: principles and interpretation. 4th ed., St Louis: Mosby; 2000.

Fig.12a

Fig.12b

Fig.12c

Fig.12d

Fig.12e

Fig.12f

Fig.12g

Fig.12h

Fig.12i

Fig.12l

图 10a

治疗后的X头影证 明避免了根尖的皮 骨质渗透； b 头影测量跟踪。 图 11

横向X线头影测量 表明正畸治疗过程 中的牙齿和骨骼的 变化：前颅底部的 上面。 图 12 (A-L) 治疗一年后。

Article courtesy of: European Journal Of Paediatric Dentistry; Vol 16/3 - 2015 © Ariesdue

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31

SCIENTIFIC UPDATE Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance

Author D. Celli.

A. L. Grego, S. Sferra, R. Deli Catholic University of Sacred Heart, Rome Italy

e-mail: simonesferra @hotmail.it KEY WORDS

dilacerated teeth; straightwire appliance; impacted maxillary central incisor.

Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance TO CITE IN THIS ARTICLE: Celli D, Greco AL, Sferra S, Deli R. Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance. Eur J Paediatr Dent 2015; 16(3): 191-196.

ABSTRACT

Aim:To describe the orthodontic management of root dilaceration of an impacted maxillary tooth following trauma to its deciduous predecessors, to show the clinical management of root dilaceration of a maxillary central incisor and describe how the dilacerated tooth was successfully moved into alignment in a young patient with a proper multidisciplinary approach, using the simple and effective straightwire technique.

Case report: After surgical exposure and orthodontic traction, the impacted dilacerated tooth was brought to alignment in the arch. The patient’s chewing and speech function, and aesthetics were restored. The radiograph shows that the root is finally straight and relatively well developed. This approach avoids extraction and prosthetic rehabilitation of the dilacerated tooth.

INTRODUCTION Andreasen et al. [1971] defined dilaceration as the abrupt deviation of the long axis of the crown or root portion of the tooth, which is due to a traumatic non-axial displacement of already formed hard tissue in relation to the developing soft tissue [Andreasen et al., 1971].

The knowledge regarding how, where and when the traumatic injury has occurred is very important in order to make a precise diagnosis during the emergency visit, and to adopt the correct and most efficient clinical procedure [Ribeiro and Campos, 2009].

The aetiology of dilaceration is not fully understood. There are two main explanations of its causes: an acute mechanical injury to the primary predecessor tooth, which causes dilaceration of the underlying developing succedaneous permanent tooth; idiopathic developmental disturbances as the cause of dilacerations, mainly in cases where there is no clear sign or history of traumatic injury [Topouzelis et al., 2010; Smith and Winter, 1981; Jafarzadeb and Abbott, 2007; Stewart, 1978]. The treatment of a dilacerated anterior tooth includes surgical exposure followed by orthodontic traction; endodontic treatment or apicectomy may be associated [Lin, 1999]. Alternatively, treatment often involves surgical removal followed by orthodontic therapy to either close the space or keep it open until the patient reaches an age when implants or prosthetic treatment can be performed.

This article presents a patient with a dilacerated maxillary right central incisor managed with a multidisciplinary approach. The dilacerated tooth was disimpacted and aligned using a simple and effective method by strategic positioning of a straightwire appliance.

CASE REPORT Diagnosis and treatment plan A 9-year-old Caucasian girl was referred by her general dentist to our examination. The chief concern was the non-eruption of the maxillary right central incisor. His parents mentioned a traumatic injury affecting the frontal oral region when the child was 5 years old.

Clinical examination revealed that the patient had a symmetric face and brachyfacial type.

Intraoral examination showed an early mixed dentition and an Angle Class I molar and canine relationship. The impaction of the maxillary right central incisor had resulted in drifting of the adjacent teeth with 32

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a resultant midline deviation (Fig. 1). A metal chain showed through the gingival tissues of tooth 1.1 area because her general dentist had performed a surgical exposure and applied a traction chain. We performed an occlusal radiograph that showed a bracket bonded to the palatal surface of the impacted tooth (Fig. 2).

Palpation of the vestibular mucosa indicated a bulge in the upper anterior area where the dilacerated incisor was probably located.

Cephalometric, panoramic and occlusal radiographs revealed that the permanent maxillary right central incisor was impacted and displayed root dilaceration. Its apical foramen appeared as a circular radiopaque area with a dark radiolucent spot in the center, known as the ‘Bull’s eye’. The tooth’s morphology and position were clearly visible in the lateral cephalometric radiograph showing a horizontally displaced tooth, with its crown rotated more than 100° from normal, and its incisal tip just below the floor of the nose (Fig. 3).

The palatal surface of the crown was facing forward “like the hand of a traffic policeman” and the root was shortened. It was not possible to exactly define the root apex on the conventional radiographs.

The analysis of the lateral cephalometric radiograph disclosed a skeletal Class II occlusion with a balanced facial pattern (Table 1).

The aim of the treatment was to guide the impacted incisor into proper alignment with the adjacent incisor teeth and to re-create a complete anterior dentition. The treatment aimed at obtaining proper crown and root alignment without further root damage while maintaining the vitality and integrity of the root of the dilacerated tooth. The purpose of the treatment was, also, to extrude the tooth with all its supporting tissues (alveolar bone and attached gingiva) and to evaluate the long-term gingival and periodontal conditions.

The approach was multidisciplinary involving a combined surgical/ orthodontic treatment.

Treatment progress A STEP (Leone®, Florence, Italy) straightwire appliance was placed on the maxillary permanent teeth to create space for the impacted central incisor (Fig. 4). Prefabricated Ni-Ti, round section, 0.014 and 0.016-inch arch wires were used to align and to level the maxillary anterior teeth. Then an open-coil spring was positioned on 0.018

Fig.1d

Fig.1e

Fig.1a

Fig. 1(a-i) Pre-treatment extraoral and intraoral photographs.

Fig.1c

Fig.1b

Fig. 2(a-b) Pre-treatment panoramic and maxillary occlusal radiographs.

Fig.1f

Fig.1h

Fig.1g

Australian archwire between teeth 2.1 and 1.2 to open up space in the arch to full availability for the dilacerated tooth.

After adequate space was obtained and the tooth began to erupt, the surgery was planned. Surgical exposure of the permanent maxillary right central incisor ensued with apical repositioning flap, so that a button could be bonded onto the labial tooth surface. The placement of a button on the labial surface allows for better palatal movement of the crown (Fig. 5). Orthodontic traction of the permanent maxillary right central incisor was accomplished by attaching the traction chain to archwires.

Alignment and leveling was then continued using a 0.020 Australian archwire with a vertical occlusal step

SNA SNB ANB Wits appraisal SN/Go-Gn FMA SN/ANS-PNS ANS-PNS / Go-Gn +1 / ANS-PNS IMPA -1 / A-Pg +1 / A-Pg OVJ OVB

Pre-treatment 81 76,5 5,5 2 34 26 8 22 112 102 2 8 5 4

Fig.1i

with an eyelet on extrusion axis. Traction was activated changing the elastic cotton thread every 2 weeks until the crown of the permanent maxillary right central incisor appeared properly oriented in the oral cavity.

The traction force was about 40 g.This treatment stage lasted 6 months (Fig. 6).

Next, the button was removed from the labial surface of the permanent maxillary right central incisor and a bracket was bonded. Prefabricated round section Ni– Ti archwires with 0.014 and 0.016 inches were used again, in sequence, on the upper teeth.

In the same time a straightwire appliance was placed on the mandibular permanent teeth.

After that, Australian 0.018 and 0.020 inch archwire were used for the total alignment of the permanent

Post-treatment 82 78 4 0 37 28 14 23 118 96 2 4 2 2

Fig.2a

Fig.3a Fig.3a

Fig. 3a Pre-treatment cephalogram showing the dilacerated maxillary incisor; Fig. 3b Celophametric tracing Table 1 Cephalometric data.

Fig.2b

Fig.3b

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SCIENTIFIC UPDATE Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance

Fig.4a

Fig. 4(a-f) Intraoral view before surgery.

Fig. 5(a-b) Surgical exposure of the impacted tooth.

Fig. 6(a-f) Progress of the orthodontic traction.

Fig.4d

Fig.4b

Fig.4e

maxillary right central incisor.

The right central incisor was brought closer to alignment, so an orthodontic bracket was bonded upside down on the labial surface to initiate labial root torque using a 0.019 x 0.025 Ni-Ti archwire. The strategic positioning of the bracket allowed a better position of the tooth root and harmonic gingival margin of the two central incisors (Fig. 7).

Treatment continued with a 0.019 x 0.025-inch SS wire with tie-back. After about 3 months the bracket on the 1.1 was repositioned normally. The finishing stage was performed by 0.018 Australian archwire.

Treatment results After 26 months of treatment the brackets were removed and permanent retention was bonded to the lingual surface of the lower anterior teeth. At the end of the treatment, the free and attached gingiva of the

Fig.4c

Fig.4f dilacerated tooth appeared acceptable (Fig. 8). The dilacerated impacted teeth was properly aligned in the dental arch restoring the masticatory, phonatory functions and patient’s aesthetics. The root appears radiographically aligned and not severely compromised (Fig. 9-11). The patient was referred to the conservative dentist for restoration of the incisal margin. The one-year follow-up showed a good maintenance of the result. Aesthetic periodontal surgery and a prosthetic treatment might be recommended in adulthood (Fig. 12).

DISCUSSION Most studies of dilaceration have concerned the maxillary central incisors, as was the case in the present study. McNamara et al. [1998] successfully aligned dilacerated maxillary central incisors planning a therapy that encompassed endodontic treatment and apico-

Fig.5b

Fig.5a

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Fig.6a

Fig.6b

Fig.6c

Fig.6d

Fig.6e

Fig.6f

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Fig.7a

Fig.7c

Fig.7b

Fig.7d

ectomy. Dilacerated impacted teeth can be properly aligned in the dental arch by appropriate treatment, which frequently requires cooperation among orthodontists, periodontists, paedodontists, endodontists, and/or prosthodontists. In the present study, no endodontic treatment or apicoectomy was needed during or after treatment, as has sometimes been required in similar cases.

A dilacerated tooth is said to be more resistant to extrusion than a tooth with a normal root, making the apical area more prone to resorption. However, in our patient, no severe root resorption could be detected, suggesting that, in the case of dilaceration, root resorption can hardly be predicted. Radiographic checkups during orthodontic traction are advisable [Cozza et al., 2005].

The success rate of an impacted dilacerated tooth alignment mainly depends on the following factors: - position and direction of the impacted tooth; - degree of root formation; - degree of dilaceration; - availability of space for the impacted tooth.

Machtei et al. [1990] also include the condition of the periodontium. McNamara et al. [1998] underline the decisive significance of the post-traumatic condition of the Hertwig’s epithelial root sheath for a successful therapeutic outcome, since normal root development depends on its integrity.

A dilacerated tooth with an obtuse inclination angle, a lower position in relation to the alveolar crest combined with an incomplete root formation has a better prognosis for orthodontic traction.

Fig.8a

Fig.8b

Fig.8c

Fig.8e

Fig.8f

Fig.8g

Fig. 7(a-d) Strategic positioning of the bracket bonded upside down.

Fig. 8(a-o) Records after debonding.

Fig.8d

Fig.8h Fig.8o

Fig.8i

Fig.8l

Fig.8m

Fig.8n

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SCIENTIFIC UPDATE Management of impacted dilacerated maxillary incisor with strategic positioning of a straightwire appliance

Fig.9

Fig. 9 Post-treatment panoramic radiograph showing no signs of root resorption of the aligned left central incisor.

Fig. 10a A Post-treatment cephalogram proving that penetration of the cortical bone from the dilacerated root apex was avoided; b cephalometric tracing.

Fig. 11 Superimpositions of the lateral cephalograms showing the dental and skeletal changes during orthodontic treatment: superimposition on the anterior cranial base (S-N).

Fig.10a

CONCLUSION The factors that determined a positive outcome are the following.

- The strategic placement of the straightwire appliance allows correct positioning of the tooth root and harmonic gingival margin of the two central incisors.

- The placement of buttons on the labial surface allows the palatal movement of the crown.

- The use of light and constant orthodontic forces (40 g) exerted by means of traction chain and elastic cotton thread before and NiTi superelastic wires.

REFERENCES › Andreasen JO, Sndström B, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors.

A clinical and histologic study of 117 injured permanent teeth. Scand J Dent Res 1971 ; 79:219–83. › Cozza P, Marino A, Condo, R. Orthodontic treatment of an impacted dilacerated maxillary incisor: a case report. J Clin Pediatr Dent Winter 2005 ; 30(2):93-7, . › Jafarzadeb H, Abbott P. Dilaceration: review of an endodontic challenge. J Endod 2007 ; 33:1025–30.

Fig.10b

Fig.11

› Lin YTJ. Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop 1999 ; 115:406–9. › Machtei EE, Zyskind K, Ben-Yehouda A. Periodontal considerations in the treatment of dilacerated maxillary incisors. Quintessence Int 1990; May 21(5):357-60. › McNamara T, Woolfe SN, McNamara CM. Orthodontic management of a dilacerated maxillary central incisor with an unusual sequel. J Clin Orthod 1998; 32:293–7. › Ribeiro D, Campos V. Prevalence of sequelae in the permanent anterior teeth after trauma in their predecessors: a longitudinal study of 8 years. Dental Traumatology 2009 ; 25:300–304. › Stewart DJ. Dilacerate unerupted maxillary central incisors. Br Dent J 1978 145: 229–33. › Smith DMH, Winter GB. Root dilaceration of maxillary incisors. Br Dent J 1981; 150:125–7. › Topouzelis N, Tsaousoglou P, Pisoka V, Zouloumis L. Dilaceration of maxillary central incisor: a literature review.

Dental Traumatology 2010; 26:427–433. › White SC, Pharoah MJ, Oral radiology: principles and interpretation. 4th ed., St Louis: Mosby; 2000.

Fig. 12 (A-L) One year post-treatment.

Article courtesy of: European Journal Of Paediatric Dentistry; Vol 16/3 - 2015 © Ariesdue

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Fig.12a

Fig.12b

Fig.12c

Fig.12d

Fig.12e

Fig.12f

Fig.12g

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Fig.12l

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SCIENTIFIC UPDATE

β-磷酸三钙在拔牙后牙槽窝中的应用

β-磷酸三钙在拔牙后牙槽窝中的应用 文章来源 Muñoz-Corcuera M, Bascones-Martínez A, Ripollés-de Ramón J. Post-extraction application of beta tricalcium phosphate in alveolar socket. J Osseointegr 2015;7(1):8-14.

摘要

Author M. Muñoz-Corcuera A.Bascones-Martínez 1 J. Ripollés-de Ramón

西班牙马德里孔普鲁 顿大学牙科学院口腔 内科和外科系

目的：本次试验的目的是评估β-磷酸三钙对促进牙槽骨的形成和防止拔牙后牙槽骨再吸收的 能力。 材料和方法：在给16位患者提取前磨牙后，牙槽窝内填充了β-磷酸三钙。6个月后，在载入种 植体的手术过程中，用环锯提取了骨样本，并进行了组织学和形态学分析。在提取和植入种 植体期间，利用数据收集表格和病理报告的方式，收集了有关患者、临床、病理以及组织形 态学上的变量数据。 结果：临床结果是令人满意的，该生物材料在X影像上显示出不透射性。组织学研究结果显 示：在愈合过程中得到适当矿化和成熟的牙槽骨部分地整合在生物材料中，还有成骨活性细 胞和含有骨细胞的骨馅窝。第6个月的时候，生物材料没有完全被吸收。 结论: 提取后，如果即刻把β-磷酸三钙填充在牙槽窝中并加以缝合，它是一种可以促进牙槽骨 保存的材料；它还能促进牙周内新骨形成。这种技术与其他可用的生物材料、生长因子和没 有得到保存的牙槽骨上的操作技术相比，还需要进行进一步研究。

1牙科学院教授l 关键词: 骨移植；磷酸钙； 牙的种植；拔牙后的 牙槽窝

引言 在正常情况下，健康的骨在不断地重塑而 且具备有效的自我修复能力。在动态过程中， 骨重建保持骨形成和骨吸收的连续平衡性来适 应局部所受的应力（1）。但是，如果高于临 界限度的话，骨不能单靠自己的成骨活性被修 复，这时候必须使用某种类型的骨移植（2）。 颚骨缺损可以由手术切除、外伤性损失、骨 化损害（一般多发于中老年人群）、牙周病、 种植体周围疾病和先天性疾病造成。由于没有 正常种植时所需的足够骨量，这些缺陷可能会 使由种植体支撑的修复治疗手术过程变得更加 复杂(3，4)。颚骨损失经常是由于拔牙后牙槽 再吸收导致的，这是一种可以导致减少牙槽脊 的高度和宽度的生理现象，其减损程度会根据 部位和患者的差异而有所不同(5)。为了解决其 带来的临床问题，特别是针对有审美需求的部 位，牙槽脊的保存技术已经被研发出来（5） 。骨移植方法包括自体骨移植、异体移植、动 物骨来源（异种骨移植）和合成骨替代物（异 质移植物），以及生长因子和基因疗法的应用 (3，4，6)。 作为一种具有生物相容性和可再吸收性的 材料，β-磷酸三钙是一种被广泛地作为替代陶 瓷的传导骨来修复骨缺损的生物材料。由于其 化学和物理的性质，它被成功地运用于各种 Fig.12l Fig.12i 行业中的空隙填充，包括生物、兽药、人类

38

DoctorOs 牙医 Infodent International •3/2017

医学、口腔医学等各种邻域中（7-12）。它还 被建议作为生长因子快速通道来刺激骨的形成 (12，13)。作为一种生物材料，已经有不同的 学者报告了它在动物和人骨再生过程中的作用 (4，14-21)。 本实验的目的是评估拔牙后在牙槽窝中填充 颗粒β-磷酸三钙的情况，并测量β-磷酸三钙对 促进新骨形成的潜在能力和对保留原始牙槽骨 重量和厚度的作用；对后续的种植手术来说， 牙槽骨的保留和修复情况是至关重要的。 具体而言，研究目标有如下4个： 1.分析从拔牙后在牙周槽中填充β-磷酸三钙到 后期的种植体的载入期间所获得的临床和组织 学结果。 2.评估β-磷酸三钙作为拔牙后的骨填充材料的 有效性。 3.在牙周槽内放置生物材料6个月后，对所形成 新骨的数量和质量进行组织学分析。 4.测定生物材料颗粒与患者骨接触的比例。

材料和方法 研究设计 这项具有前瞻性的临床研究符合赫尔辛基宣 言的原则，并由西班牙马德里圣卡洛斯临床医 院的临床研究伦理委员会批准。 所有参与研究的患者年龄在18岁以上，根据 计划，每位患者将拔除一至四颗的前磨牙并在 后期种植新牙，拔除四颗磨牙的患者占所有受

试者的四分之一，拔牙原因有牙周疾病、龋齿 和骨折等。受试者排除标准为:没有签署知情同 意书者，不愿意遵守预定研究日程者，带有由 外科手术、术中或术后药物影响而导致的疾病 者，牙槽窝壁缺损者，每日吸烟10支或10支以 上者，因为吸烟的习惯可以导致种植的失败， 在研究开始前一个月内有过双膦酸盐或抗生素 治疗者。患者均从临床口腔学院（西班牙孔普 卢顿大学）和私人牙科诊所中招募。患者的选 择是通过非概率连续抽样法进行，并且只选择 符合上述标准的个体。 有16名患者在2008年三月到2010年七月间被 纳入研究对象，这16名患者平均年龄为44.3 岁 （标准偏差年龄为：10.74）；男性7个（占 44%），平均年龄为39.7岁；女性9个(占56%)， 平均年龄为48岁。没有一个受试者(0%)是每日 饮酒者，2个(占12%)患者是每日吸烟者（每天 1至9支）。一共有19颗上磨牙和2颗下磨牙被 拔除（由于下磨牙的数量太少，最后并没有纳 入研究数据分析中）。 在一个基准临床评估后，所有患者均接受了基 本的术前牙周治疗，并被告之在整个研究过程 中都要保持良好的口腔卫生。

手术步骤 通过局部麻醉后，整片颊舌瓣被翻起，拔 掉磨牙；一整片颊舌瓣被抬起，以便于通过缝 合来固定颗粒状的填充材料。用手术刮匙清除 牙槽中的所有肉芽组织，并在牙槽中填充由生 理盐水或患者血液混合了0.5克 KeraOs β-磷酸 三钙（由西班牙 拉科鲁尼亚的Keramat公司生 产）的填充物（图1）。然后，通过重新定位 牙周冠瓣后进行了牙槽缝合(图2)。指导患者每 天用0.12%的葡萄糖酸氯己定冲洗口腔两周。

在拔牙后的7到10天时拆除了缝合线。 在种植手术期间，用环锯（环锯内径为2.2 mm，外径3 mm）切下了一片样品骨，并放置 在福尔马林缓冲液中送到加利西亚陶瓷研究所 （在西班牙的Santiago de Compostela）实验室 进行研究。

组织的处理 按照多纳特方法，利用精确的系统对样品骨 进行了加工，使其变成未脱钙的薄片。 简单来说，就是将样品固定在10%福尔马林 缓冲液中，并用酒精使其逐渐脱水，再将其 镶入光聚合性的丙烯酸甲酯树脂中。经过聚合 后，用金刚石锯将样品切割，然后用金刚砂纸 研磨至约70微米的宽度。变薄后，把样品放在 Levai Laczko 染色剂和2R/Harris苏木精中进行 染色。为了获得组织形态学的测量数据，使用 了以下设备：一个带有奥林巴斯DP71摄影机 的电动奥林巴斯BX51显微镜使样品成像，用 奥林巴斯D-cell细胞捕获软件、Photoshop CS3 图像处理软件、采用Wacom Intuos4数位板和 奥林巴斯显微图像4.0程序。 所收集数据如下：

图 1 牙槽窝中填充了β-磷 酸三钙和患者血液的 混合物 图 2 用冠瓣顶部重新定位 后牙槽窝被缝合。 表1 结果，单个个体的变 量。平均年龄44.3岁 (标准偏差：10.74); 7个男性（占44%） 平均年龄为39.7岁， 9个女性（占56%） 平均年龄为48岁。 没有患者（0%） 是每日饮酒者，有2 个患者（12%）每天 抽烟1-9根。

1. 患者变量，根据性别、年龄、酒精和烟的消 费情况来分类（吸烟者每日1至9支，不吸烟者 每日0支，以便于测试轻量吸烟是否会影响到 牙槽的康复）。 2.临床变量分生物材料在牙槽中的稳定性和种 植体的初期稳定性 3.放射学发现 4.6个月时候的组织学变量，牙槽中新骨形成 的程度，所形成新骨的总量和质量，患者骨和

FEMALES

MALES

MEAN

STANDARD DEVIATION

Age (yrs)

48

39.7

44.3

10.47

Number

9 (56.25%)

7 (43.75%)

Smokers (1-9 cigs/day)

2 (12%)

0 (0%)

Drinkers

0 (0%)

0 (0%) DoctorOs 牙医 Infodent International •3/2017

39

SCIENTIFIC UPDATE

β-磷酸三钙在拔牙后牙槽窝中的应用

β-磷酸三钙结合的程度，β-磷酸三钙的吸收程 度，这些均直接通过显微镜观察评估。 5.组织形态学变量：新骨形成区域、不成熟 骨、原骨、生物材料和层状骨、骨与生物材料 接触指数（与骨接触的材料周长 /整块材料的 周长）、残留体积（当前材料表面 /[所剩材料 表面积+ 总骨表面积]）、不成熟骨:成熟骨的 比值（成熟骨表面 / 总骨表面）。 图 3 新形成骨在生物材料 的周围, (白色箭头所 指之处)，在活组织 样品的中心区有微弱 的再吸收迹象(红色 箭头处)。大部分的 骨是新形成骨，周围 有旧骨痕迹。 Levai-Laczko 染 色，100倍。 图 4 生物材料整合 在骨组织中；松懈结 缔组织占优势（红色 箭头处），虽然也有 一部分在密致结缔组 织区域内，生物材料 整合在骨小梁中 (白色箭头所指 之处)。Levai-Laczko 染色，100倍。 图 5 生物材料被不成熟骨 包围，变色2R/哈里 斯染色.100倍。 表2 结果，形态学变量的 描述性统计；表格显 示了每个变量的最大 值和最小值；也显示 了每个变量的中值和 均值。

40

我们用专门设计的表格处理了在以下时间点 收集的数据:拔牙、采集患者变量、缝合线的拆 除（在拔牙后7至10天）记录反射学发现、种 植手术（大约在拔牙6个月后），采集影像学 研究结果和材料保留在牙槽中的数据、种植体 初期的稳定性。组织学数据是从种植时采样的 病理报告中获得的。 Microsoft Excel和SPSS软件被用于统计分析， 其中包括：对患者、临床和组织形态学变量的 描述性分析；为描述组织形态变量用了频率直 方图；为组织形态学而运用的Shapiro-Wilks正 态性检验，患者年龄和恢复时间，形态学变量 的可信区间为95%，用Pearson相关系数，来分 析形态学变量与每个不同的恢复时间和患者年 龄之间的差异，通过方差分析来确定愈合时间 对新骨形成区、生物材料区以及骨与生物材料 接触指数的影响。而由学生进行的T检验法却 把新骨形成区和骨与生物材料接触指数与愈合 时间的长短进行了比较（5至6个月的愈合时间 相比于7至8个月的愈合时间）。

结果 患者变数 一个男性患者在进行种植手术之前放弃了研 究，在剩下的15个患者中采集到了21个样品， 这些患者的平均愈合时间为6.2个月（标准差 为±1.05）。在21个样品中，有3个样品在研磨 过程中受损而无法进行评估，还有2个由于不

MINIMUM VALUE

VARIABLE (%)

MAXIMUM VALUE

MEAN

MEDIAN

STANDARD DEVIATION

Newly formed bone area

0.30

45.33

20.15

13.64

15.42

Immature bone area

8.34

31.80

20.07

20.07

16.58

Old bone area

0.43

21.03

11.98

11.87

7.65

Biomaterial area

0.33

26.25

11.40

7.99

8.88

Lamellar bone area

2.02

6.11

4.06

4.06

2.89

Bone-implant contact index 0

69.70

32.31

19.82

24.94

Remnant volume

0

98.85

31.98

35.60

25.68

Immature bone-mature bone relationshop

0

96.07

42.62

36.13

36.48

DoctorOs 牙医 Infodent International •3/2017

正确取样而被排除在参与分析的可能之外。因 此，我们最终对16个样品进行了组织学和形态 学分析。

临床结果 在种植过程中，没有患者被发现有明显的生 物材料流失，在一些病例中，从最表面来看， 移植的残留颗粒对外科手术和种植的初步稳定 性没有影响，而所有的病例都获得了成功的手 术过程和初步的稳定性。X射线图像显示没有 并发症，在所有的黏膜中后来被确定检测到了 高不透射线的材料。 组织学和形态学结果 在被分析的16个样品中，没有检测到生物材 料的碎片和坏死骨碎片，在三个病例中，生物 材料已经融合在骨中，并被具有骨纤维和骨基 质边缘的纤维组织包围；在一个病例中，生物 材料被松弛的结膜组织包围；在5个病例中， 生物材料被成熟的骨小梁、少量类骨质和成骨 细胞包围；在7个病例中，从少量到高度丰富 的带有类骨质和成骨细胞边缘的不成熟骨小梁 的生长迹象。活组织样品中的10个显示出有纤 维化骨髓的存在，但其中大部分样品中的存在 比例较低。 在牙槽中发现了很明显的活骨生长现象，且 新形成骨与移植颗粒紧密结合。所有样品中都 发现了材料的残留颗粒，那些残留颗粒都有不 同程度的重塑和再吸收迹象（图3、4和5）。 6个月时的组织学研究显示，牙槽中新形成 骨为一般中等程度，刚形成的新骨还未成熟（ 这和愈合时间的长短有一定的关系）并被生物 材料碎片包围或与其直接接触，而β-磷酸三钙 材料显示出再吸收的初步现象。 表2展示了组织形态学变量结果，呈现出正 态分布状体（用Shapiro-Wilk检测法)。15个活 组织样品中8个样品的频率直方图显示骨和生

物材料接触面积为<20%，而其中大部分样品 的刚形成新骨面积为>20%；大部分活组织样 品中的生物材料面积为<20%。除了由于只在 2个样品中获得了测量数据的未成熟骨和层状 骨变量外，计算显示其他所有变量均显示出非 常不错的95%的可信区间(表3)。这两个变量被 排除在分析之外，用Pearson相关系数，找出 各个组织形态学变量之间和愈合时间于年龄之 间的相关性，在残留体积和生物材料面积之间 的相关系数为正相关（p= 0.0056），旧骨面积 和不成熟骨面积与成熟骨比值的相关性为(p= 0.015)。 虽然本次研究的预期恢复时间为6个月，但 这个期限有时被患者的具体情况受到影响而变 成了5至8个月。我们分析了恢复时间对新形成 骨的面积、生物材料面积以及骨与生物材料接 触指数结果的影响，并没有发现显著异常。之 后又把新形成骨面积、生物材料面积以及骨与 生物材料接触指数的结果分别与5到6个月的愈 合时间的病例与7到8个月愈合时间的病例做了 比较，也没有发现很大的差异，尽管新骨形成 的面积获得了较高的临界意义(p=0.08)。

表3 结果，形态学变量的 描述性统计；表格显 示了每个变量的最大 值和最小值；也显示 了每个变量的中值和 均值。

讨论 在本次研究中，在牙槽中放置β-磷酸三钙没 有引发任何并发症，并且获得了良好的临床结 果。在植入种植体时有存在骨形成的组织学证 据，还有骨细胞和不成熟骨的存在。新形成 骨的平均百分比为20.15%，与之前的报告一致 （22-25）。在大部分的活组织样品中，生物 材料的面积为小于20%，证实了生物材料的再 吸收能力。生物材料在X射线影像中可以被很 容易的识别出来，并且比相邻骨要密致得多， 就如Von Doernberg等学者在之前报道的一样 （26）。生物材料的这个特征对后期愈合中的 X射线很有用，因为不透射线会随着材料被吸 收和被新骨取代而改变。

VARIABLE

Upper Interval limit

Lower interval limit

Statistical significance

Newly formed bone area

29.95

10.35

Significant

Immature bone area

169.11

-128.97

Not Significant

Old bone area

19.06

4.91

Significant

Biomaterial area

18.23

4.58

Significant

Lamellar bone area

30.04

-21.92

Not Significant

Bone-implant contact index

46.12

18.49

Significant

Remnant volume

46.20

17.76

Significant

Immature bone: mature bone ratio 63.69

21.56

Significant

DoctorOs 牙医 Infodent International •3/2017

41

SCIENTIFIC UPDATE

β-磷酸三钙在拔牙后牙槽窝中的应用

对人类的临床研究一般要求用非侵入技术，如X射线；但 在评估骨再生、骨体积和骨质量时，用一个活组织样品进 行研究是目前最好的方法。分两个阶段的研究方法可以使 我们获得组织学样品（20），第一步放置移植物，第二步 进行种植，本次研究用的便是这种方法。 由于这种颗粒状多孔材料的不易操作性(27)，我们把β-磷 酸三钙混合在生理盐水或患者自身血液中使用，根据Horowitz等学者提出的方案（24)。 我们决定了愈合时间为6个月，因为大部分的陶瓷已经被 吸收，并且认为被移植的组织有足够的稳定性来负载种植 体（19，24）。一项对猪的研究发现，β-磷酸三钙的降解 性趋于缓慢，在28周时只有80%的材料被吸收，到86周时 有97%的材料被吸收；因此，作者建议在移植区域移植和 种植的间隔时间应该为5到6个月，结论认为，细胞对同步 移植的反应有可能损害种植体的骨整合。一些学者建议通 过延长愈合时间来提高种植的初步稳定性（4），且发现在 9个月的时候有残留颗粒的存在已经不影响种植手术(23)。 于此相反，如上报告，Ormianer等学者在被扩充部位进行 了即刻填充和种植体载入，他们他们获得了97%的成功率 （22）。 至于β-磷酸三钙在被骨取代前的降解机制，Wiltfang等学者 认为（28）是通过化合水解和巨噬细胞的活性（多核巨噬 细胞）达成的。至今有两种降解途径被描述出来：破骨细 胞介导的吸收和组织液中溶解（23）。2005年的一项研究 表明，他们在上颌窦底部填充β-磷酸三钙6个月后所获得的 一个组织样品中并没有检测到活性破骨细胞，但这个结论 并不能排除有活性破骨细胞的参与，即便认为它的存在是 有限的（29）。除了这两种机制外，据推测，β-磷酸三钙 还可能被破骨细胞以外的其他细胞介导（20)。然而，Martinez等学者（30）却提出破骨细胞或巨噬细胞在β-磷酸三钙 的再吸收中可能并没有起到很重要的作用，因为他们在骨 与β-磷酸三钙的接口细胞中发现了网状内皮系统。 可以找到一些关于用β-磷酸三钙来保存牙槽骨的资料 （22-25）。Ormianer在338个患者上单独使用了β-磷酸三 钙，虽然没有对所有患者的牙槽骨保留状态进行调查， 而且接受不同治疗方法的患者数目也未被指明；平均随 访时间为19.2个月，整体的种植存活率为97.6%.。在2008 年，Brkovic报告了他在一个患者身上使用了β-磷酸三钙和 胶原蛋白的混合物，愈合时间为9个月，他的报告得出了具 有骨形成迹象的良好临床结果。 在2012年，Horowitz在30个患者的牙槽窝中填充了β-磷酸 三钙和薄膜，平均愈合时间为6个月，他也得到了良好的临 床结果，保留了牙槽骨91%的宽度。最后，在同年，Brkovic进行了对20个患者的研究，他把患者分成两组，其中一 组患者的牙槽窝中填充了β-磷酸三钙和薄膜的混合物并用 龈翼重新定位顶部，而另外一组则只用β-磷酸三钙填充， 两组的平均愈合时间为9个月，得出的结论是，没有添加薄 膜的患者组的牙槽骨保存程度更低。我们的结果跟这四个 研究的结果是有可比性的，因为本次研究的种植体存活率 为100%，临床结果是良好的，在活组织样品中观察到了骨 形成，并且只有少量的残留骨，为11.98%（表2）。 还有一些用其他材料来保存牙槽骨的报告，比如，Liasella

42

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等学者运用了同种异体移植方法也得到了良好的结果（31 ），而De Coster等学者则运用了双向性陶瓷材料，但他们 得到的结果并不好，也因此推迟了种植手术（32）。 由于在从环锯上提取样品时碰到了一些困难，我们改变了 提取方法，我们把样品放置在一起再用环锯加工。Zerbo也 发现单片的β-磷酸三钙活组织样品很难从环锯上移除（33) 。Suba 也报道过，他经常在样品加工过程中损坏生物材料 颗粒。由于样品处理的复杂性，本次研究中，在抛光过程中 损失了三个样品，还有一个样品在不正确的部位被提取，而 一些学者则用外科手术指南解决了这个问题（25）。 Horowitz在2010（34）年的一项研究中讨论了两个病 例，第一个病例的方法与本次研究描述的方法几乎完全一 致，不同的是，在放置生物材料后他还使用了可吸收性薄 膜。他得出的临床结果非常好，在拔牙6个月后可以进行种 植。生物材料被新的活骨取代，就如我们试验中的结果一 样。第二个病例是一个吸烟患者，在牙槽中填充生物材料 后也运用了薄膜，在这个例子中，愈合时间为10个月，完 成种植后的临床、放射和组织学结果与我们本次研究的的 结果有可比性。由于增加了愈合时间，他们在活组织样品 中观察到了骨单元和哈弗僧系统的形成。 这项研究有一些局限性，尤其是小尺寸的样品。组织学 结果和临床结果与一些学者在之前报告的结果是一致的， 在6个月的时候，不受限制的愈合时间、在扩充部位中种植 的初期稳定性，还有β-磷酸三钙颗粒充足地被新形成骨取 代。

结论 此次研究的临床和影像学结果是另人满意的，没有引 起相关的并发症。在拔牙后，如果把β-磷酸三钙即刻放 入牙槽窝中并缝合的话，β-磷酸三钙似乎是一个能够保 存牙槽骨的生物材料；在头6个月中它还能促进牙槽窝 中的新骨形成。这种具有再吸收性的材料使可预见和可 重复的骨再生变成了可能，由此我们可以看到它无限的 可能性，容易处理和巨大的不透射性，对后期愈合中的 放射过程很有帮助。已经有各种出版物表明了这种材料 在骨增长技术运用中的稳定性。与其他可用的生物材 料、生长因子和没有经过保存的牙槽脊运用技术相比， 这项技术还需要进一步的临床研究和随机临床试验。 鸣谢 这项研究由西班牙教育部给大学教授的FPU培训基金(nº AP2008-00011)，和Universidad-Empresa基金与Keramat所签 署项目(47/2009)共同资助。

参考文献 1. Allegrini S Jr, Koening B Jr, Allegrini MR, Yoshimoto M, Gedrange T, Fanghaenel J et al. Alveolar ridge sockets preservation with bone grafting-review. Ann Acad Med Stetin 2008;54:70-81.

2. Khan Y,Yaszemski MJ, Mikos AG, Laurencin CT.Tissue engineering of bone: material and matrix considerations. J Bone Joint Surg Am 2008;90(Suppl 1):36-42.

3. Tripplet RG, Schow SR, Laskin DM. Oral and maxillofacial surgery advances in implant dentistry. Int J Oral Maxillofac Implants 2000;15:47-55.

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

5. Darby I, Chen S, De Poi R. Ridge preservation: what is it and when should

it be considered. Aust Dent J 2008;53:11-21.

6. Giannoudis PV, Dinopoulos H, Tsiridis E. Bone substitutes: an update.

Injury 2005;36 Suppl 3:S20-7.

7. Deppe H, Horch H, Neff A. Conventional versus CO2 laser-assisted treatment of peri-implant defects with the concomitant use of pure-phase ß-tricalcium phosphate: a 5-year clinical report. Int J Oral Maxillofac Implants 2007;22:79-86.

8. Franch J, Díaz-Bertrana C, Lafuente P, Fontecha P, Durall I. Beta-tricalcium phosphate as a synthetic cancellous bone graft in veterinary orthopaedics. A retrospective study of 13 clinical cases. Vet Comp Orthop Traumatol 2006;19:196-204.

9. Gan Y, Dai K, Zhang P, Tang T, Zhu Z, Lu J. The clinical use of enriched bone marrow stem cells combined with porous beta-tricalcium phosphate in posterior spinal fusion. Biomaterials 2008;29:3973-82.

10. Liu G, Zhao L, Cui L, Liu W, Cao Y. Tissue-engineered bone formation using human bone marrow stromal cells and novel beta-tricalcium phosphate. Biomed Mater 2007;2:78-86.

11. Allabouch A, Colat-Parros J, Salmon R, Naim S, Meunier JM. Biocompatibility of some materials used in dental implantology: histological study.

Colloids Surf B Biointerfaces 1993;1:323-9.

12. Aybar B, Bilir A, Akçakaya H, Ceyhan T. Effects of tricalcium phosphate bone graft materials on primary cultures of osteoblast cells in vitro. Clin Oral Impl Res 2004;15:119-25.

13. Byun H, Wang H. Sandwich bone augmentation using recombinant human platelet-derived growth factor and beta-tricalcium phosphate alloplast: case report. Int J Periodontics Restorative Dent 2008;28:83-7.

14. Alam S, Ueki K, Marukawa K, Ohara T, Hase T, Takazakura D et al.

Expression of bone morphogenetic protein 2 and fibroblast growth factor 2 during bone regeneration using different implant materials as onlay bone graft in rabbit mandibles. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:16-26.

15. Boix D, Weiss P, Gauthier O, Guicheux J, Bouler JM, Pilet P et al.

Injectable bone substitute to preserve alveolar ridge resorption after tooth extraction: a study in dog. J Mater Sci Mater Med 2006;17:1145-52.

16. Fiorellini JP, Kim DM, Nakajima Y, Weber HP. Osseointegration of titanium implants following guided bone regeneration using expanded polytetrafluoroethylene membrane and various bone fillers. Int J Periodontics Restorative Dent 2007;27:287-94.

17. Masago H, Shibuya Y, Munemoto S, Takeuchi J, Umeda M, Komori T et al. Alveolar ridge augmentation using various bone substitutes--a web form of titanium fibers promotes rapid bone development. Kobe J Med Sci 2007;53:257-63.

18. Suba Z, Takács D, Gyulai-Gaäl S, Kovács K. Facilitation of beta-tricalcium phosphate-induced alveolar bone regeneration by platelet-rich plasma in beagle dogs: a histologic and histomorphometric study. Int J Oral Maxillofac Implants 2004;19:832-8.

19. Horch HH, Sader R, Pautke C, Neff A, Deppe H, Kolk A. Synthetic, pure-phase beta-tricalcium phosphate ceramic granules (Cerasorb) for bone regeneration in the reconstructive surgery of the jaws. Int J Oral Maxillofac Surg 2006;35:708-13.

20. 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 Oral Impl Res 2006;17:102-8.

implants in deficient alveolar bone sites augmented with beta-tricalcium phosphate. Implant Dent 2006;15:395-403.

23. Brkovic BM, Prasad HS, Konandreas G, Milan R, Antunovic D, Sándor GK et al. Simple preservation of a maxillary extraction socket using beta-tricalcium phosphate with type I collagen: preliminary clinical and histomorphometric observations. J Can Dent Assoc 2008;74:523-8.

24. Horowitz RA, Mazor Z, Miller RJ, Krauser J, Prasad HS, Rohrer MD. Clinical evaluation of alveolar ridge preservation with a beta-tricalcium phosphate socket graft. Compend Contin Educ Dent 2009;30:588-90, 592, 594 passim; quiz 604, 606 25. 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 socket healing: clinical, histologic, histomorphometric, and immunohistochemical evaluation. Clin Oral Investig 2012;16:581-90.

26. von Doernberg MC, von Rechenberg B, Bohner M, Grünenfelder S, van Lenthe GH, Müller R et al. In vivo behavior of calcium phosphate scaffolds with four different pore sizes. Biomaterials 2006;27:5186-98.

27. Walsh WR, Vizesi F, Michael D, Auld J, Langdown A, Oliver R et al.

Beta-TCP bone graft substitutes in a bilateral rabbit tibial defect model.

Biomaterials 2008;29:266-71.

28. Wiltfang J, Merten HA, Schlegel KA, Schultze-Mosgau S, Kloss FR, Rupprecht S et al. Degradation characteristics of alpha and beta tri-calcium-phosphate (TCP) in minipigs. J Biomed Mater Res 2002;63:115-21.

29. Zerbo IR, Bronckers AL, de Lange G, Burger EH. Localisation of osteogenic and osteoclastic cells in porous beta-tricalcium phosphate particles used for human maxillary sinus floor elevation. Biomaterials 2005;26:1445-51.

30. Martinez A, Franco J, Saiz E, Guitian F. Maxillary sinus floor augmentation on humans: Packing simulations and 8 months histomorphometric comparative study of anorganic bone matrix and ß-tricalcium phosphate particles as grafting materials. Mater Sci Eng C Mater Biol Appl 201015;30:763-9.

31. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA et al. 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;74:990-9.

32. De Coster P, Browaeys H, De Bruyn H. Healing of extraction sockets filled with BoneCeramic® prior to implant placement: preliminary histological findings. Clin Implant Dent Relat Res 2011;13:34-45.

33. Zerbo IR, Zijderveld SA, de Boer A, Bronckers AL, de Lange G, ten Bruggenkate CM et al. Histomorphometry of human sinus floor augmentation using a porous beta-tricalcium phosphate: a prospective study. Clin Oral Implants Res 2004;15:724-32.

34. Horowitz RA, Mazor Z, Foitzik C, Prasad H, Rohrer M, Palti A. b-tricalcium phosphate as bone substitute material: properties and clinical applications. J Osseointegr 2010;2(2):61-68.

21. Szabó G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabas J et al. A prospective multicenter randomized clinical trial of autogenous bone versus beta-tricalcium phosphate graft alone for bilateral sinus elevation: histologic and histomorphometric evaluation. Int J Oral Maxillofac Implants 2005;20:371-81.

22. Ormianer Z, Palti A, Shifman A. Survival of immediately loaded dental

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SCIENTIFIC UPDATE Post-extraction application of beta-tricalcium phosphate in alveolar socket

Post-extraction application of beta-tricalcium phosphate in alveolar socket TO CITE IN THIS ARTICLE: Muñoz-Corcuera M, Bascones-Martínez A, Ripollés-de Ramón J. Post-extraction application of beta tricalcium phosphate in alveolar socket. J Osseointegr 2015;7(1):8-14.

ABSTRACT

Author M. Muñoz-Corcuera A.Bascones-Martínez 1 J. Ripollés-de Ramón Department of Oral Medicine and Surgery, School of Dentistry, Madrid Complutense University, Madrid, Spain 1 Professor at dental school KEY WORDS

Bone graft; Calcium phosphate; Dental implant; Post-extraction alveolar socket.

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Aim The objective of this study was to assess the capacity of beta-tricalcium phosphate to facilitate bone formation in the socket and prevent post-extraction alveolar resorption.

Materials and methods After premolar extraction in 16 patients, the sockets were filled with beta-tricalcium phosphate. Six months later, during the implant placement surgery, a trephine was used to harvest the bone samples which were processed for histological and histomorphometrical analyses. Data were gathered on patient, clinical, histological and histomorphometric variables at the extraction and implant placement sessions, using data collection forms and pathological reports.

Results Clinical outcomes were satisfactory, the biomaterial was radio-opaque on X-ray. Histological study showed: partial filling with alveolar bone of appropriate maturation and mineralization for the healing time, osteoblastic activity and bone lacunae containing osteocytes. The biomaterial was not completely resorbed at six months.

Conclusion Beta-tricalcium phosphate is a material capable of achieving preservation of the alveolar bone when it is positioned in the immediate post-extraction socket followed by suture; it also helps the formation of new bone in the socket. Further studies are needed comparing this technique with other available biomaterials, with growth factors and with sites where no alveolar preservation techniques are performed.

INTRODUCTION In normal conditions, healthy bone is under continuous remodelling and has an effective self-repair capacity.

Bone remodelling maintains a continuous balance of bone formation and resorption in a dynamic process that adapts the bone to local forces (1). Above a critical defect size, however, bone cannot be repaired by its own osteogenic activity, and some type of bone grafts must be used (2).

Jaw bone defects can be caused by surgical resection, traumatic loss, ossification impairment (in the elderly), periodontal and peri-implant diseases and congenital disorders. These defects may complicate the surgical phase of implant supported rehabilitation treatment due to insufficient bone volume for an adequate implantation (3, 4). Jaw bone loss is frequently caused by post-extraction alveolar resorption, a physiological phenomenon which leads to a reduction of the original height and width of the alveolar ridge to a degree that varies among localizations and patients (5). Alveolar ridge preservation techniques have been developed to address the ensuing clinical problem, especially in aesthetic areas (5). They are conducted during or after extraction and are designed to minimize external ridge resorption and maximize bone formation inside the socket (5). Measures include autologous bone grafts, allografts, bone of animal origin (xenografts) and synthetic bone substitutes (alloplastic grafts), as well as the application of growth factors and gene therapies (3, 4, 6).

Beta-tricalcium phosphate (beta-TCP) is widely used as a biocompatible, resorbable and osteoconductive ceramic substitute to repair bone defects. Thanks to its

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physicochemical characteristics, it has been successfully used to fill spaces in multiple settings, including biology, veterinary medicine, human medicine and dentistry (712). It has also been proposed as a vehicle for growth factors that stimulate bone formation (12, 13). Various authors have reported on its capacity as a biomaterial for bone regeneration in animals and humans (4, 1421).The study is aimed at evaluating granular beta-TCP in post-extraction sockets in order to measure its bone regenerative potential and its capacity to preserve the original height and width of the alveolar bone for subsequent implant placement.

Specifically, the study objectives were the following.

1. To analyze the clinical and radiological results obtained after placement of the biomaterial in the post-extraction socket and at the subsequent insertion of dental implants.

2. To assess the effectiveness of beta-TCP as bone filling material in the post-extraction socket.

3. To perform histological analysis of the amount and quality of bone formed in the dental socket six months after the placement of the biomaterial.

4. To determine the percentage of biomaterial particles in contact with patient bone.

MATERIALS AND METHODS Study design This prospective longitudinal observational clinical study complied with the principles of the Helsinki Decl0aration and was approved by the clinical research ethics committee of the San Carlos Clinical Hospital, Madrid (Spain). All patients in the study were aged over 18 years and scheduled for ≥ 1 premolar extraction due

Fig.1

Fig.2

to periodontal disease, caries or fractures and for subsequent replacement with dental implant(s) up to a maximum of four premolar extractions (one per quadrant) per patient. Exclusion criteria were: failure to sign informed consent or commit to compliance with the study appointment schedule; the presence of endocrine-metabolic disease or chronic, general or local disease; the presence of disease that may be affected by the surgery or by the intraoperative or postoperative medication; alveolar socket wall defects; smoking habit of ≥10 cigarettes/day, due to its relationship with implant failure; and treatment with bisphosphonates or antibiotics during the previous month. Patients were recruited from the School of Dentistry clinic (Complutense University of Madrid, Spain) and private clinics.

A non-probabilistic sampling of consecutive cases was conducted and only patients who met the above criteria were included. Sixteen patients were enrolled in the study between March 2008 and July 2010, with a mean age of 44.3 years (standard deviation: 10.74); seven were male (44%) with mean age of 39.7 years and nine were female (56%) with mean age of 48 years. No participant (0%) was a daily drinker of alcohol, and two (12%) were daily smokers (of 1-9 cigarettes). A total of 19 upper and 2 lower teeth were extracted (lower teeth were excluded from the analysis because of this small number). After a baseline clinical assessment, all patients received basic periodontal therapy before the surgery and were instructed to maintain good oral hygiene throughout the study.

Surgical procedure After applying local anaesthesia and performing fullthickness buccal and lingual flap elevation, the premolar was extracted; a full-thickness flap was elevated to enable a subsequent suture to keep the granules of the material in place. Any granulation tissue present in the socket was removed by surgical curettage, and the socket was filled with 0.5 g beta-TCP KeraOs®

(Keramat, La Coruña, Spain) mixed with physiological saline solution or blood from the same patient (Fig. 1).

The socket was then closed by suture using a coronally repositioned flap (Fig. 2). Patients were instructed to rinse daily for two weeks with 0.12% chlorhexidine digluconate. Sutures were removed at 7-10 days post-extraction. During the implant placement surgery (about 6 months after biomaterial placement), a bone biopsy was harvested using a trephine (inner diameter of 2.2 mm, outer diameter of 3 mm), placed in a 10% buffered formalin and sent to the Ceramic Institute of Galicia (Santiago de Compostela, Spain) laboratory for processing.

Histological processing The specimens were processed to obtain thin undecalcified sections following Donath’s method and using the EXACT system.

Briefly, specimens were fixed in buffered 10% formalin, progressively dehydrated in alcohol and then embedded in photopolymerizable methacrylate resin (Technovit 7200®, VLC-Heraus Kulzer GMBH, Werheim, Germany). After polymerization, the specimens were cut with a diamond saw and then ground with silicon carbide papers to a width of about 70 microns. After thinning, samples were stained with Levai Laczko stain and chromotrope 2R/Harris haematoxylin. A motorized Olympus BX51 microscope with Olympus DP71 camera was used to image the specimens, with Olympus D-cell capture software and Photoshop CS3 image processing software, employing a Wacom Intuos 4 pen tablet and applying the Olympus MicroImage 4.0 program to obtain histomorphometric measurements.

Data were gathered on the following.

1. Patient variables, sex, age, and consumption of alcohol and cigarettes (smoker = 1-9, non-smoker = 0 cigarettes/day, to test whether a light tobacco habit affects socket healing).

2. Clinical variables, biomaterial stability within socket

FEMALES

MALES

MEAN

STANDARD DEVIATION

Age (yrs)

48

39.7

44.3

10.47

Number

9 (56.25%)

7 (43.75%)

Smokers (1-9 cigs/day)

2 (12%)

0 (0%)

Drinkers

0 (0%)

0 (0%)

Fig. 1 Socket filled with a mixture of beta-TCP and patient blood.

Fig. 2 Socket closed by suture using a coronally repositioned flap.

Table 1 Results. Variables related to the individual. Mean age 44.3 yrs (standard deviation: 10.74); 7 males (44%) with mean age 39.7 yrs and 9 females (56%) with mean age 48 yrs. No participant (0%) was a daily drinker of alcohol, and two (12%) were daily smokers of 1-9 cigarettes.

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SCIENTIFIC UPDATE Post-extraction application of beta-tricalcium phosphate in alveolar socket

Fig. 3 Newly formed bone around the biomaterial, (white arrows) with faint signs of resorption in the central area of the biopsy (red arrow). Most of the bone is newly formed, with traces of old bone at the periphery.

Levai-Laczko stain.

100X. Fig. 4 Material integrated in the bone tissue; there is a predominance of lax connective tissue (red arrow), although with areas of denser connective tissue. The biomaterial is integrated in bone trabeculae (white arrows). Levai-Laczko stain. 100X. Fig. 5 Biomaterial surrounded by immature bone. Chromotrope 2R/Harris haematoxylin staining.100X. Table 2 Results. Descriptive statistics of histomorphometric variables.

Table shows the minumim and maximum values for each variable; the mean and the median are also showed for each variable.

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and primary implant stability.

3. Radiological findings.

4. Histological variables at 6 months, degree of bone neoformation in socket, amount and quality of newly formed bone, degree of contact between patient bone and beta-TCP and degree of beta-TCP resorption, all assessed by direct microscopic observation.

5. histomorphometric variables, areas of newly formed bone, immature bone, old bone, biomaterial and lamellar bone, bone-biomaterial contact index (perimeter of material in contact with bone / perimeter of whole material), remnant volume (surface of material present / [surface of material present + total bone surface]) and immature:mature bone ratio (mature bone surface / total bone surface).

Specifically designed forms were used to collect data at the following time points: tooth extraction, gathering patient variables; suture withdrawal (7-10 days post-extraction), recording radiological findings; and implant placement (around 6 months post-extraction), gathering radiological findings and data on material retention in the socket and primary implant stability.

Histological data were obtained from the pathology report on samples taken at implant placement.

Microsoft Excel and SPSS were used for the statistical analyses, which included: descriptive analysis of patient, clinical and histomorphometric variables; frequency histograms for histomorphometric variables; Shapiro-Wilks normality tests for histomorphometric variables, age and healing time; 95% confidence intervals for histomorphometric variables; use of the Pearson correlation coefficient to analyse associations of different histomorphometric variables with each other and with healing time and age; analysis of variance (ANOVA) to determine the effect of healing time on newly formed bone area, biomaterial area and bone-biomaterial contact index; and the Student’s t test to compare newly formed bone area, biomaterial area and bone-biomaterial contact index between shorter and longer healing times (5-6 months versus 7-8 months, respectively).

MINIMUM VALUE

VARIABLE (%)

Fig.3

Fig.4

Fig.5

MAXIMUM VALUE

MEAN

MEDIAN

STANDARD DEVIATION

Newly formed bone area

0.30

45.33

20.15

13.64

15.42

Immature bone area

8.34

31.80

20.07

20.07

16.58

Old bone area

0.43

21.03

11.98

11.87

7.65

Biomaterial area

0.33

26.25

11.40

7.99

8.88

Lamellar bone area

2.02

6.11

4.06

4.06

2.89

Bone-implant contact index 0

69.70

32.31

19.82

24.94

Remnant volume

0

98.85

31.98

35.60

25.68

Immature bone-mature bone relationshop

0

96.07

42.62

36.13

36.48

DoctorOs 牙医 Infodent International •3/2017

RESULTS Patient variables One male patient abandoned the study before implant placement. Among the 15 remaining patients, 21 biopsies were obtained after a mean healing time of 6.2 months (standard deviation: ±1.05). Out of the 21 biopsies, 3 were impaired during grinding and could not be processed, and 2 were incorrectly sampled and excluded from the analyses. Hence histological and histomorphometric analyses were conducted in a final sample of 16 biopsies (Table 1).

Clinical results None of the patients evidenced biomaterial loss at implant placement; in some cases, the most superficial area showed residual graft particles that had no effect on the surgical procedure or primary stability, which was obtained in all cases. X-ray images revealed no complications, and in all the films, high radiopacity and consequent prompt identification of the material was detected.

Histological and histomorphometric results No biomaterial fragments or necrotic bone splinters were detected in any of the 16 biopsies analyzed. In three cases, the biomaterial was integrated in the bone and surrounded by fibrous tissue with rim of osteoblasts and osteoid matrix; in one case, the biomaterial was surrounded by lax conjunctive tissue; in five cases, it was surrounded by mature bone trabeculae with scant osteoid and osteoblastic rimming; in seven cases, modest to highly abundant immature bone trabeculae growth was observed with osteoid and osteoblasts rim. Ten of the biopsies showed the presence of medullary fibrosis, at a low level in most cases.

Evidence of vital bone growth was found in the sockets, with bone neoformation in close contact with graft particles. All samples showed residual particles of the material, with various degrees of material remodelling and resorption (Fig. 3, 4, 5).

The histological study at 6 months revealed that the

degree of bone neoformation in the socket was generally moderate, that the newly formed bone was immature (consistent with the healing time) and surrounded by and in direct contact with biomaterial fragments and that the beta-TCP material showed initial signs of resorption.

Table 2 exhibits the results of the histomorphometric variables, which were found to follow a normal distribution (Shapiro-Wilk test). The frequency histograms showed that the mean contact between bone and biomaterial was <20% in 8 out of 15 biopsies and that the newly formed bone area was >20% in most of them; the biomaterial area was <20% in most of the biopsies. Calculation of 95% confidence intervals showed significance for all variables, except for the immature bone area and lamellar bone area, for which there were measurements in only two cases (Table 3). These two variables were excluded from analysis, using Pearson’s correlation coefficient, of the relationships of histomorphometric variables with each other and with healing time and age; a positive correlation was found between remnant volume and biomaterial area (p= 0.0056) and between old bone area and the immature bone:mature bone ratio (p= 0.015).

Although the healing period was established as 6 months for this study, this time was sometimes influenced by specific patient circumstances and ranged from 5 to 8 months. The results for newly formed bone area, biomaterial area and bone-biomaterial contact index were analyzed in function of healing time, finding no significant differences. Then, newly formed bone area, biomaterial area and bone-biomaterial contact index were compared between healing times of 5-6 months and 7-8 months, finding no significant differences, altough borderline significance (p=0.08) was obtained for newly formed bone area.

Table 3 Results. 95% confidence intervals. Calculation of 95% confidence intervals showed significance for all variables, with the exception of immature bone area and lamellar bone area, for which there were measurements in only two cases.

DISCUSSION In this study, post-extraction placement of beta-TCP in the socket did not cause any complications and achieved good clinical outcomes. There was histological evi-

VARIABLE

Upper Interval limit

Lower interval limit

Statistical significance

Newly formed bone area

29.95

10.35

Significant

Immature bone area

169.11

-128.97

Not Significant

Old bone area

19.06

4.91

Significant

Biomaterial area

18.23

4.58

Significant

Lamellar bone area

30.04

-21.92

Not Significant

Bone-implant contact index

46.12

18.49

Significant

Remnant volume

46.20

17.76

Significant

Immature bone: mature bone ratio 63.69

21.56

Significant

DoctorOs 牙医 Infodent International •3/2017

47

SCIENTIFIC UPDATE Post-extraction application of beta-tricalcium phosphate in alveolar socket dence of bone neoformation at implant placement, with the presence of osteocytes and immature bone. The mean percentage of neoformed bone was 20.15%, in line with previous reports (22-25). The biomaterial area was less than 20% in most of the biopsies, confirming the resorbability of the biomaterial. The biomaterial was readily identifiable on X-ray, being much denser than the adjacent bone, as previously reported by Von Doernberg et al. (26). This characteristic is useful for the radiographic follow-up of healing, because the radiopacity changes as the material is resorbed and replaced by new bone.

Clinical studies on humans generally require the use of non-invasive techniques, e.g. radiology; but a biopsy study is the currently optimal method to assess the regeneration, quantity and quality of bone. A two-phase approach, inserting the graft in the first phase and the implant in the second, allows a histological sample to be obtained (20).

This technique was applied in the present study.

We mixed beta-TCP with saline solution or blood from the patient, as in the study by Horowitz et al. (24), given the difficulty of managing this porous material in granular form (27).

Six months as bone healing time was selected, because most of the ceramic is resorbed, and the grafted tissue can be considered sufficiently stable for functional implant loading (19, 24). A study in pigs (28) found beta-TCP degradation to be slow, with 80% of the material resorbed at 28 weeks and 97% at 86 weeks; therefore, the authors recommended an interval of 5-6 months before implant placement in grafted areas, concluding that the cell response to their simultaneous placement could damage implant osseointegration. Some authors suggested lengthening this healing time in order to increase implant stability (4), and it was found that the presence of residual particles at 9 months does not compromise implant placement (23). In contrast, as reported above, Ormianer et al. achieved a 97% success rate after the immediate placement of implants in augmented areas and their immediate implant loading (22).

With regard to the mechanism of beta-TCP degradation before its substitution by bone, it was attributed by Wiltfang et al. (28) to chemical hydrolysis (halisteresis) and the activity of phagocytic cells (multinucleated giant cells). Two degradation pathways have since been described: osteoclast-mediated resorption and dissolution in interstitial fluid (23). A study in 2005 detected no osteoclastic activity in biopsies from sinuses augmented with this biomaterial, but this finding does not rule out the participation of osteoclasts although it suggested that it is limited (29). Besides these two mechanisms, it has been postulated that beta-TCP resorption may also be mediated by cells other than osteoclasts (20). However, Martinez et al. (30) suggested that osteoclasts or macrophage cells may not play an important role in beta-TCP resorption, as they found in the bone-beta-TCP interface cells of the reticuloendothelial system. Some data are available on the use of beta-TCP for alveolar preservation (22-25). Ormianer studied the use of beta-TCP alone in 338 patients, although alveolar preservation was not investigated in all of these, and the number of patients undergoing the different procedures was not specified; the mean follow-up was 19.2 months and the global implant survival rate was 97.6%. In 2008, Brkovic reported on the use of beta-TCP with collagen alone in one patient, followed up for 9 months, reporting good clinical outcomes with bone formation activity.

In 2012, Horowitz used beta-TCP with a membrane in 30 patients, followed up for a mean of 6 months, also observing good outcomes with preservation of 91% of the socket width. Finally, in the same year, Brkovic studied 20 patients in two groups, one receiving beta-TCP with membrane and apically repositioned flap and the other beta-TCP alone, with a mean follow-up of 9 months, concluding that socket preservation was lower in the group without membrane. Our

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results are comparable to the findings of these four studies, because the implant survival was 100%, the clinical outcomes were good, bone neoformation was observed in the biopsies, and there was only a small volume of residual bone (11.98%) (Table 2).

There have also been reports on socket preservation with the use of other materials. Thus, Liasella et al. employed allografts with good results (31), while De Coster et al. (32) used biphasic ceramics but obtained poor outcomes that delayed implant placement.

After experiencing some problems in harvesting the specimens from the trephine, the protocol was modified and the samples were processed with the trephine as a block. Zerbo (33) also found it difficult to remove beta-TCP biopsies in a single piece from the trephine, and Suba (20) reported that biomaterial particles frequently broke during sample preparation.

In the present study three biopsies were lost in the polishing process, due to the complexity of sample processing, and one biopsy was taken from the incorrect area, a problem that some authors have resolved by using surgical guides (25).

In the study by Horowitz 2010 (34), two cases are discussed. In the first one an identical procedure to the one here described was followed, except for the use of a resorbable membrane after the placement of the biomaterial. The clinical outcome was excellent, allowing the placement of a dental implant 6 months after extraction. The biomaterial was replaced by new vital bone, just as in our work. Their second case is that of a smoker patient; the biomaterial was placed in the socket followed by a membrane. Healing time in this case was 10 months, after which an implant was placed.The clinical, radiological and histological results are comparable to those of our study, they observed the formation of osteon and Haversian systems in the biopsy due to increased healing time.

With the limitations of this study, especially regarding the small sample size, the histological and clinical results are in agreement with reports by various authors, evidencing problem-free healing, primary stability of implants placed in the augmented area, and an adequate substitution of beta-TCP particles by newly formed bone at 6 months.

CONCLUSION The clinical and radiographic outcomes of this procedure are satisfactory, with no associated complications. Beta-tricalcium phosphate seems to be a biomaterial capable of achieving preservation of the alveolar bone when it is positioned immediately in post-extraction socket followed by suture; also facilitating the formation of new bone in the socket in the first six months. This resorbable material allows predictable and reproducible bone regeneration. As advantages, it can be noted its unlimited availability, its easy handling and its great radiopacity, allowing radiographic follow-up of the area. Multiple publications have shown the suitability of this material for use in bone augmentation techniques. Further clinical studies and randomized clinical trials are needed, comparing this technique with other available biomaterials, with growth factors and with alveoli in which no alveolar preservation techniques are performed.

ACKNOWLEDGEMENTS This study was supported by an FPU training grant for university professors from the Spanish Ministry of Education (nº AP2008-00011) and by a project of Universidad-Empresa Foundation (47/2009) signed with Keramat.

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2. Khan Y,Yaszemski MJ, Mikos AG, Laurencin CT.Tissue engineering of bone: material and matrix considerations. J Bone Joint Surg Am 2008;90(Suppl 1):36-42.

3. Tripplet RG, Schow SR, Laskin DM. Oral and maxillofacial surgery advances in implant dentistry. Int J Oral Maxillofac Implants 2000;15:47-55.

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

5. Darby I, Chen S, De Poi R. Ridge preservation: what is it and when should it be considered. Aust Dent J 2008;53:11-21.

6. Giannoudis PV, Dinopoulos H, Tsiridis E. Bone substitutes: an update.

Injury 2005;36 Suppl 3:S20-7.

7. Deppe H, Horch H, Neff A. Conventional versus CO2 laser-assisted treatment of peri-implant defects with the concomitant use of pure-phase ß-tricalcium phosphate: a 5-year clinical report. Int J Oral Maxillofac Implants 2007;22:79-86.

8. Franch J, Díaz-Bertrana C, Lafuente P, Fontecha P, Durall I. Beta-tricalcium phosphate as a synthetic cancellous bone graft in veterinary orthopaedics. A retrospective study of 13 clinical cases. Vet Comp Orthop Traumatol 2006;19:196-204.

9. Gan Y, Dai K, Zhang P, Tang T, Zhu Z, Lu J. The clinical use of enriched bone marrow stem cells combined with porous beta-tricalcium phosphate in posterior spinal fusion. Biomaterials 2008;29:3973-82.

10. Liu G, Zhao L, Cui L, Liu W, Cao Y. Tissue-engineered bone formation using human bone marrow stromal cells and novel beta-tricalcium phosphate. Biomed Mater 2007;2:78-86.

11. Allabouch A, Colat-Parros J, Salmon R, Naim S, Meunier JM. Biocompatibility of some materials used in dental implantology: histological study.

Colloids Surf B Biointerfaces 1993;1:323-9.

12. Aybar B, Bilir A, Akçakaya H, Ceyhan T. Effects of tricalcium phosphate bone graft materials on primary cultures of osteoblast cells in vitro. Clin Oral Impl Res 2004;15:119-25.

13. Byun H, Wang H. Sandwich bone augmentation using recombinant human platelet-derived growth factor and beta-tricalcium phosphate alloplast: case report. Int J Periodontics Restorative Dent 2008;28:83-7.

14. Alam S, Ueki K, Marukawa K, Ohara T, Hase T, Takazakura D et al.

Expression of bone morphogenetic protein 2 and fibroblast growth factor 2 during bone regeneration using different implant materials as onlay bone graft in rabbit mandibles. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:16-26.

15. Boix D, Weiss P, Gauthier O, Guicheux J, Bouler JM, Pilet P et al.

Injectable bone substitute to preserve alveolar ridge resorption after tooth extraction: a study in dog. J Mater Sci Mater Med 2006;17:1145-52.

16. Fiorellini JP, Kim DM, Nakajima Y, Weber HP. Osseointegration of titanium implants following guided bone regeneration using expanded polytetrafluoroethylene membrane and various bone fillers. Int J Periodontics Restorative Dent 2007;27:287-94.

17. Masago H, Shibuya Y, Munemoto S, Takeuchi J, Umeda M, Komori T et al. Alveolar ridge augmentation using various bone substitutes--a web form of titanium fibers promotes rapid bone development. Kobe J Med Sci 2007;53:257-63.

18. Suba Z, Takács D, Gyulai-Gaäl S, Kovács K. Facilitation of beta-tricalcium phosphate-induced alveolar bone regeneration by platelet-rich plasma in beagle dogs: a histologic and histomorphometric study. Int J Oral Maxillofac Implants 2004;19:832-8.

19. Horch HH, Sader R, Pautke C, Neff A, Deppe H, Kolk A. Synthetic, pu-

re-phase beta-tricalcium phosphate ceramic granules (Cerasorb) for bone regeneration in the reconstructive surgery of the jaws. Int J Oral Maxillofac Surg 2006;35:708-13.

20. 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 Oral Impl Res 2006;17:102-8.

21. Szabó G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabas J et al. A prospective multicenter randomized clinical trial of autogenous bone versus beta-tricalcium phosphate graft alone for bilateral sinus elevation: histologic and histomorphometric evaluation. Int J Oral Maxillofac Implants 2005;20:371-81.

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

23. Brkovic BM, Prasad HS, Konandreas G, Milan R, Antunovic D, Sándor GK et al. Simple preservation of a maxillary extraction socket using beta-tricalcium phosphate with type I collagen: preliminary clinical and histomorphometric observations. J Can Dent Assoc 2008;74:523-8.

24. Horowitz RA, Mazor Z, Miller RJ, Krauser J, Prasad HS, Rohrer MD. Clinical evaluation of alveolar ridge preservation with a beta-tricalcium phosphate socket graft. Compend Contin Educ Dent 2009;30:588-90, 592, 594 passim; quiz 604, 606 25. 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 socket healing: clinical, histologic, histomorphometric, and immunohistochemical evaluation. Clin Oral Investig 2012;16:581-90.

26. von Doernberg MC, von Rechenberg B, Bohner M, Grünenfelder S, van Lenthe GH, Müller R et al. In vivo behavior of calcium phosphate scaffolds with four different pore sizes. Biomaterials 2006;27:5186-98.

27. Walsh WR, Vizesi F, Michael D, Auld J, Langdown A, Oliver R et al.

Beta-TCP bone graft substitutes in a bilateral rabbit tibial defect model.

Biomaterials 2008;29:266-71.

28. Wiltfang J, Merten HA, Schlegel KA, Schultze-Mosgau S, Kloss FR, Rupprecht S et al. Degradation characteristics of alpha and beta tri-calcium-phosphate (TCP) in minipigs. J Biomed Mater Res 2002;63:115-21.

29. Zerbo IR, Bronckers AL, de Lange G, Burger EH. Localisation of osteogenic and osteoclastic cells in porous beta-tricalcium phosphate particles used for human maxillary sinus floor elevation. Biomaterials 2005;26:1445-51.

30. Martinez A, Franco J, Saiz E, Guitian F. Maxillary sinus floor augmentation on humans: Packing simulations and 8 months histomorphometric comparative study of anorganic bone matrix and ß-tricalcium phosphate particles as grafting materials. Mater Sci Eng C Mater Biol Appl 201015;30:763-9.

31. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA et al. 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;74:990-9.

32. De Coster P, Browaeys H, De Bruyn H. Healing of extraction sockets filled with BoneCeramic® prior to implant placement: preliminary histological findings. Clin Implant Dent Relat Res 2011;13:34-45.

33. Zerbo IR, Zijderveld SA, de Boer A, Bronckers AL, de Lange G, ten Bruggenkate CM et al. Histomorphometry of human sinus floor augmentation using a porous beta-tricalcium phosphate: a prospective study. Clin Oral Implants Res 2004;15:724-32.

34. Horowitz RA, Mazor Z, Foitzik C, Prasad H, Rohrer M, Palti A. b-tricalcium phosphate as bone substitute material: properties and clinical applications. J Osseointegr 2010;2(2):61-68.

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SCIENTIFIC UPDATE 长4毫米的种植体在下颚无齿且垂直骨量受限患者中的运用评估。手术初步结果

长4毫米的种植体在下颚无齿且垂直骨量 受限患者中的运用评估。 手术初步结果 J.L. CALVO-GUIRADO1, M. MALLAUN2, M. DARD3, J.A. LÓPEZ TORRES4 1西班牙穆尔西亚大学 2瑞士巴塞尔士卓曼研 究所 3美国纽约大学 4西班牙穆尔西亚大学 关键词 : 骨密度、插入扭矩、 短种植体、成功率

文章来源: Calvo-Guirado JL, Mallaun M, Dard M, López Torres JA. Evaluation of 4 mm implants in mandibular edentulous patients with reduced bone height. Surgical preliminary results. J Osseointegr 2014;6(2):43-45.

摘要 目的 ：越来越多的迹象表明了短种植体在垂直骨量受限口腔修复过程中的运用。此短论的目 的是评估小于10毫米的种植体在临床中的运用，并找出短种植体支撑的假牙在下颚萎缩患者 中的成功运用方案。 材料和方法：我们招募了六个女性和三个男性进行接受下颌牙的修复，在每位患者的下颌中 植入六根种植体:其中两根常规种植体在前部，4根4毫米钛锆合金的种植体在后部。并对种植 体的插入扭矩和骨密度进行了评估。 结果：4毫米种植体的插入扭矩的平均值低于常规种植体的插入扭矩，但没有很明显的差异。 此外大部分患者 (88%)显现出D2骨型。 结论：从短期来讲，给萎缩牙槽嵴的患者植入短种植体支撑的假牙似乎是一个成功的治疗选 择；不过，从长期来看，我们还需要更多的科学依据。 引言 在全无齿患者的口腔修复中，运用传统的 可移动假牙可能会由于以下原因使患者不满 意，不稳定性、不适、挤压神经和影响吃饭与 说话的能力。在这种情况下，一个用螺丝固定 在种植体上的假牙可以作为一个可行的替代方 案。然而，缺乏充足的骨量和过于接近下齿槽 神经，可能会给骨内种植造成一个临床上的难 题。通过运用短种植体来避免这些难题的话， 初步稳定性可能会由于减少了骨结合的接触面 积而受限制。况且，成功地在密致骨中放置短 种植体还需要用一个精确的手术技巧来避免孔 位过大和骨位被过分加热的情况。传统上，临 床医生们已经避免了在受损骨中运用短种植体 (如后置、低密度骨质、薄边等)。然而通过建 立新的表面，短种植体的手术和临床性能可能 变得和标准长度种植体非常相似。 此短论的主要目的是对这种4毫米短种植体 的手术性能进行评估和报道，该种植体由钛锆 合金制成，其表面具有亲水性。 材料和方法 我们招募了六个女性和三个男性进行下颌牙 修复，三男六女的平均年龄为64岁（最小年龄 为44岁最大年龄为86岁）在告知该实验的目的 后，我们给每位测试者详尽地讲解了所有需要 遵循的要求和治疗过程，包括治疗的原计划和 替代程序。还给研究对象解释了潜在风险、可 能出现的并发症、和被推荐的治疗的好处，然 后，他们都签下了一个意向书。 研究对象是根据以下两条标准筛选出来的： 需要达到的标准：研究对象年龄在18岁以上， 承诺参与研究3年以上；下颌全无齿，可以植 入6根种植体（尖牙区的两根10毫米和四根4毫

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DoctorOs 牙医 Infodent International •3/2017

米长的在颏神经后面的再吸收区域）；全牙和 部分牙列不适合种植体的植入。种植部位的无 齿时间需多于两个月，并且伤口已痊愈，有骨 再吸收和萎缩状态；残留骨的重量必须与尖牙 区所需标准一致，后面的区域至少有8毫米。 排除标准：有血液、代谢、内分泌、肾脏或肿 瘤性疾病的人，有人类免疫缺陷病毒感染者， 每天抽烟超过10支者，酗酒者；以及所有可能 妨碍参与正常研究实验或干扰分析结果的条 件；有粘膜疾病者；有放射治疗史者；或在手 术预期植入部位有过修复、挫骨、骨再生失败 的人；有严重的夜磨牙症或咬牙习惯者；不充 分的口腔卫生或无意在家护理口腔卫生者；缺 乏初步稳定性者；骨量不足或有任何一种不支 持种植手术的异常条件者。

疗前处理程序 对研究对象的口腔进行了临床和影像检查， 包括全景X光线 (图 1) （由美国纽约Carestream 公司生产的8000C全景和X线头影数字系统 ） 和锥束扫描（由美国纽约Carestream公司生产 的CS9300系统）。通过利用启发式分割法，骨 和非骨的三维像素被分离，这种专门用于骨组 织而研发的分割方，是通过利用不均匀的CT 衰减密度而研发出来的。 研究规划 每位患者被植入六根种植体：尖牙区两根 长10毫米的种植体和后部四根有亲水性表 面长4毫米的种植体( 瑞士巴塞尔StraumannAG士卓曼研究所研发的Tissue Leval系标准 RN，Roxolid,SLActive4.1毫米的种植体),以便于

Fig.1

Fig.2

图1 术前全景X线片。

Fig.3 安装螺丝固定式的假牙。

手术过程 用单次手术植入种植体。用下牙槽神经阻滞 和注射含有1:100.000肾上腺素的牙用阿提卡因 进行了局部麻醉。在第一磨牙远端面的牙槽嵴 上切开了中切线，整个厚度的黏骨膜襟翼被翻 起，并在后部用两个释放切口标出颏孔的路劲 走向(图2).种植部位的准备工作按照精确的顺 序进行(图3)。术后立即通过记录4毫米植入物 的插入扭矩评估了种植体的初始稳定性。压盖 螺丝被安装在种植体上，襟翼被重新定位后缝 合(图4)。 医师经过斟酌定量开了抗生素服用处方， 为了控制疼痛给出了止痛药。并指导患者 用0.12%的洗必泰溶液冲洗口腔（该溶液由 西班牙巴塞罗那Dentaid公司生产），每天2 次，坚持1到2周，直到拆线为止。拆线后， 患者被要求以正确的动作用1%的氯己定胶 凝涮洗植入物直到种植部位最终修复为止。 利用临时植入物上的结构，把一个可移动的 临时修复体安装在颌骨上（该临时修复体由 德国库克斯的VOCO有限公司提供）。为了 避免在愈合期间给最终植入物过大的压力 和负荷，手术前后都进行了全景X摄影(图5). 统计分析 统计所用软件名为StatXact(该软件由美国马 塞诸塞州剑桥市的Cytel公司开发 )，我们还用 Excel进行了描述性统计（Excel由美国华盛顿

图2 植入种植体前粘骨膜 瓣被翻起。

Fig.4 州雷德蒙德市的微软公司开发）。在测试中病 人被用作分析的个体单位，为了后续的数据， 我们为每个患者计算出了平均值。在计算中使 用了配对样本 t-检验法，最后显著性水平显示 为0.05.

结果 直到植入一个月后，所有的种植体都存活 了下来，4毫米种植棒的插入扭矩为38.1 ± 1.2 Ncm,，长度为10毫米的种植棒的插入扭矩为 42.4 ± 2.1 Ncm（表1）。运用配对样本 t-检验 法，平均插入扭矩之间没有显著差异(p=0.005) (图6) 。 讨论和结论 为了避免种植失败，应该由技术娴熟的专家 来种植短种植体，这项研究的初步结果表明， 长4毫米由钛锆合金制成且具有亲水性表面的 种植体，可以安全地植入有再吸收性情况的下 颌骨中，它的插入扭矩与更长的种植体插入扭 矩不相上下。因此也可以避免用垂直扩充的程 序。与下颌骨（2013年，在蒙特利尔市麦吉尔 大学的一个会议上总结出一个关于下颌骨义齿 种植体数量的共识）不同的是，如今没有针对 上腭义齿种植体数量的共识。然而，最近的一 个系统综述表明，根据上颚上的种植体和义齿 的存活率来看，由六根种植体连着一根横着的 铁丝来固定义齿是最为成功的治疗方案(6)。本 实验提议的4根超短种植体的使用，可能会导 致成本增加，但是，通过增加固定树脂义齿的 稳定性，它们对长种植体是不无裨益的，因为

图3 给4毫米种植体的钻孔 顺序：兰斯型钻 (设计成尖钻利于打破 皮骨质)；2,2毫米钻 (为了初始植入种植体); 种植体深度记； 2.8毫米钻；种植体深 度记；3.5毫米钻；种 植体深度计。 图4 六根种植体被种植在 无牙颌上，两根10毫 米长的种植棒和四根4 毫米种植棒在后面心 智神经的两侧。

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SCIENTIFIC UPDATE 长4毫米的种植体在下颚无齿且垂直骨量受限患者中的运用评估。手术初步结果

Fig.5

图5 种植后的术后X线片。 图6 每位患者的平均插入 扭矩，插入4毫米种植 体时的记录。 表1 平均插入扭矩(Ncm)+/, 标准偏差(SD)，每位患 者（患者1到患者9), 4毫米种植体插入过程 中的记录。

PATIENT

P1

P2

P3

P4

P5

P6

P7

P8

P9

Ncm

35

41

36

54

52

39

39

48

36

SD

0

11

5.6

6.4

14

7.2

1.5

7.5

7.5

它们有更高的拱形接触面积。它还有一个优点 是可以防止后期骨再吸收情况，这意味着可以 少换几次义齿，并且可以防止颏神经受损。 Pieri 等人建议，通过用加短种植体、早期 负载来支撑假牙的方案，甚至在IV类骨质中都 有可能取得成功的修复(7)。后部低骨质/密度 的区域，可以通过一个固定甲板把种植体捆版 在一起来得到弥补（8）。 就短期而言，给下颚萎缩的患着放置用短种 植体支撑的义齿似乎是个成功的治疗选择；但 是，在本次实验中，不管是在早期阶段还是在 最终修复后都没有用辅助铁丝和早期的负载； 此外，为了降低牙槽骨的损失，在手术后的最 初几周内进行了偶尔的更换义齿。Van Assche 等学者认为还缺乏关于不同方向的拱形条件所 产生的力度的信息。由于研究中的患者数量有 限，无法评估反向拱形所产生的力度的影响。 根据此治疗概念，他们还认为短种植体可以成 功地替代骨增量技术，包括在III类骨质和IV类 骨质中，但从长期而言，还需要更多的科学依 据。

参考文献

1. Annibali S, Cristalli MP, Dell’Aquila D, Bignozzi I, La Monaca G, Pilloni A. Short dental implants: a systematic review. J Dent Res 2012;91(1):25-32.

2. Anitua E, Alkhraist MH, Piñas L, Begoña L, Orive G. Implant survival and crestal bone loss around 52

DoctorOs 牙医 Infodent International •3/2017

extra-short implants supporting a fixed denture: the effect of crown height space, crown-to-implant ratio, and offset placement of the prosthesis. Int J Oral Maxillofac Implants 2014;29(3):682-689.

3. Grandin M, Berner S, Dard M. A review of titanium zirconium (TiZr) alloys for use in endosseous dental implants. Materials, 2012, 5: 1348-1360.

4. Kim DG, Christopherson GT, Dong XN, Fyhrie DP, Yeni YN. The effect of microcomputed tomography scanning and reconstruction voxel size on the accuracy of stereological measurements in human cancellous bone. Bone 2004;35(6):1375-82.

5. Slotte C, Gronningsaeter A, Halmoy AM, Ohrnell LO, Stroh G, Isaksson S, Johansson LA, Mordenfeld A, Eklund J, Embring J. Four-millimeter implants supporting fixed partial dental prostheses in the severely resorbed posterior mandible: two-year results. Clin Implant Dent Rel Res 2011;14:46-58.

6. Slot W, Raghoebar GM, Vissink A, Huddleston Slater JJ, Meijer HJA. A systematic review of implant-supported maxillary overdentures after a mean observation period of at least 1 year. J Clin Periodontol 2010;37:98-110.

7. Pieri F, Aldini NN, Fini M, Marchetti C, Corinaldesi G. Immediate functional loading of dental implants supporting a bar-retainedmaxillary overdenture: preliminary 12-month results. J Periodontol 2009;80:18831893.

8. Van Assche N, Michels S, Quirynen M, Naert I. Extra short dental implants supporting an overdenture in the edentulous maxilla: a proof of concept. Clin Oral Impl Res 2012;23:567-576.

C L A S S E

A

w w w . a n t h o s . c o m

L I M I T L E S S

S O L U T I O N S

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2017, 25-28 October | DenTech China | Booth A61-A62-A89-A90, Hall 01 Shanghai World Expo Exhibition and Convention Center, Shanghai, P.R. China

SCIENTIFIC UPDATE Evaluation of 4 mm implants in mandibular edentulous patients with reduced bone height. Surgical preliminary results

Evaluation of 4 mm implants in mandibular edentulous patients with reduced bone height.

Surgical preliminary results TO CITE IN THIS ARTICLE: Calvo-Guirado JL, Mallaun M, Dard M, López Torres JA. Evaluation of 4 mm implants in mandibular edentulous patients with reduced bone height. Surgical preliminary results. J Osseointegr 2014;6(2):43-45.

ABSTRACT

Author J.L. CALVO-GUIRADO1, M. MALLAUN2, M. DARD3, J.A. LÓPEZ TORRES4 1 University of Murcia, Murcia, Spain 2 Institut Straumann, Basel, Switzerland 3 New York University, New York, USA 4 UNIVERSITY OF MURCIA, MURCIA, SPAIN KEY WORDS

bone density, insertion torque, short implants, success rate.

Aim Growing evidence has suggested the utility of short dental implants for oral reconstructive procedures in clinical situations of limited vertical bone height. The aim of this short comunication was to evaluate the clinical use of implants < 10 mm in length and to determine short implant-supported prosthesis success in the atrophic jaw.

Materials and methods Six women and three men were recruited for the treatment of edentulous mandibles. A total of 6 implants were inserted in each patient: two anterior implants of conventional lenght and four posterior 4 mm Titanium Zirconium (TiZr) implants. The insertion torque and bone density were evaluated.

Results The mean insertion torque for the 4 mm implants was lower than for conventional ones, without any statistical difference. Moreover, most of the patients (88%) showed a D2 bone type.

Conclusion The provision of short implant-supported prostheses in patients with atrophic alveolar ridges appears to be a successful treatment option in the short term; however, more scientific evidence is needed for the long term.

INTRODUCTION Rehabilitation of totally edentulous patients with conventional removable dentures could be unsatisfactory for patients due to instability, discomfort, nerve punching and affection of the ability to eat and speak. A complete screw-retained implant-supported prosthesis may be a viable alternative in such cases. However, the lack of sufficient bone volume and close proximity to the inferior alveolar nerve may represent a difficult clinical situation for the placement of endosseous implants (1). By using short implants to circumvent these difficulties, the primary stability may be compromised due to the reduced contact area for osseointegration.

Moreover, successful placement of short implants in dense bone may furthermore depend on an accurate surgical technique to prevent a loose fit and overheating of the bone site (2-3). Traditionally, clinicians have avoided the use of short-length implants in areas of compromised bone (e.g., posterior locations, low bone density, and thin ridges). With the introduction of new surfaces, the surgical and clinical performance of short-length implants may become very similar to that of standard length ones.

The main purpose of this short communication was to evaluate and report the surgical performance of novel short 4 mm implants made of Titanium Zirconium (TiZr) alloy with a hydrophilic surface.

MATERIAL AND METHODS Six women and three men with a mean age of 64 (range 44–86) years were recruited for treatment of edentulous mandibles. Each individual was thoroughly informed of the overall requirements/procedures of the study after explaining the purposes of the study, the nature of the planned treatment and alternative procedures.

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Potential risks, possible complications, and benefits of the proposed treatment were explained to the study subjects and they all signed an informed consent. The inclusion and exclusion criteria were selected as follows. › Inclusion criteria: age >18 years; committed to participate up to 3 years follow-up; complete edentulism in the mandible to allow placement of 6 implants (two in the canines zone of 10 mm in lenght and four 4 mm implants placed in the resorbed sites behind the mental nerve); full or partial dentition opposing the implants. The implant site had to be edentulous for >2 months and healed, with evidence of bone resorption and atrophy; the minimal residual bone height should be adequate in the canine zone, and at least 8 mm in the posterior zone. › Exclusion criteria: presence of blood, metabolic, endocrine, renal, or neoplastic disease; human immunodeficiency virus infection; smoking >10 cigarettes per day; alcoholism; any conditions that may prevent study participation or interfere with analysis of results; mucosal diseases; history of irradiation therapy; previous reconstruction, bone grafting, or failed GBR at the site of intended implant surgery; severe bruxism/ clenching; inadequate oral hygiene or unmotivated for home care; lack of primary stability; insufficient bone or any abnormality that would contraindicate implant placement.

Pretreatment procedures A clinical and radiological examination was carried out including panoramic x-rays (Fig. 1) (8000C Digital Panoramic and Cephalometric System, Carestream, Rochester, NY, USA) and Cone beam scan (CS 9300

Fig.1

Fig.2

Fig. 1 Preoperative panoramic radiograph.

Fig. 2 Mucoperiosteal flap elevated before implant placement.

Fig.3 System, Carestream, Rochester, NY, USA). Bone and non-bone voxels were segmented using a heuristic segmentation algorithm that was developed specially for bone tissue with highly nonhomogeneous CT attenuation density distributions (4).

Study design Each patient received 6 implants: two anterior implants of 10 mm length and four posterior implants of 4 mm lenght with a hydrophilic surface (Tissue Level Standard Plus, RN, Roxolid, SLActive, diameter 4.1 mm, Institut Straumann AG, Basel, Switzerland) for a screw-retained fixed complete denture.

Surgical procedure Implant placement was performed using single-stage surgery. Local anesthesia was achieved by inferior alveolar nerve block and administration of an appropriate dose of Articaine dental® 4% with epinefrine 1:100.000 (Inibsa, Barcelona, Spain). A midline incision was done at the alveolar crest from the distal surface

Fig.4 of the missing first molar. Full thickness mucoperiosteal flaps were raised and the path of the mental foramen identified with two realease incisions at the back (Fig. 2). The preparation of the implant sites was performed according to a precise sequence (Fig. 3). Immediately postoperatively, the initial implant stability was assessed by recording the insertion torque value of the 4 mm implants. Cover screws were placed on the implants and the flaps were repositioned and sutured (Fig. 4). Antibiotics were prescribed at the discretion of the surgeon. Analgesics were given as required for pain control. The patients were instructed to rinse with a 0.12% chlorhexidine solution (Dentaid, Barcelona, Spain) twice a day for 1 or 2 weeks until suture removal. After suture removal, the patients were instructed in proper mechanical brushing of the implants using 1% chlorhexidine gel until placement of the final restoration. A removable temporary prosthesis was installed in the mandible by using provisional implants loaded with Structur (Voco Gmbh, Cuxhaven, Germany), in order to avoid stress/load on the definitive implants

Fig. 3 Drilling sequence for 4mm Standard Plus Implants: Lance-shaped drill (pointed drill designed to break the cortical bone); 2,2mm drill (initial step for dental implant); Implant Depth Gauge; 2,8mm drill; Implant Depth Gauge: 3,5mm drill; Implant Depth Gauge.

Fig. 4 Six implants placed in edentulous mandible, two long implants of 10mm lenght and 4mm implants behind mental nerve in both sides.

Fig.5 Preoperative radiograph after implant placement

Fig.5 DoctorOs 牙医 Infodent International •3/2017

55

SCIENTIFIC UPDATE Evaluation of 4 mm implants in mandibular edentulous patients with reduced bone height. Surgical preliminary results

PATIENT

P1

P2

P3

P4

P5

P6

P7

P8

P9

Ncm

35

41

36

54

52

39

39

48

36

SD

0

11

5.6

6.4

14

7.2

1.5

7.5

7.5

during the healing phase. Panoramic radiographs were obtained before and after surgery (Fig. 5).

Fig.6 Mean insertion torque values per patient, recorded during the insertion of the 4mm implants.

Table 1 Mean insertion torque values (Ncm)+/- standard deviation (SD) per patient (P1 to P9), recorded during the insertion of the 4mm implants.

Statistical analysis The statistical software used was StatXact (Cytel, Cambridge, MA, USA) and descriptive statistics by means of Excel (Microsoft, Redman, WA, USA). The patient was used as the unit of analysis in all tests.

For continuous data, a mean value was calculated per patient. The paired two-sample t-test was used and the level of significance was set at 0.05.

RESULTS All implants survived until one month after insertion.

The mean insertion torque for the 4 mm implants was 38.1 ± 1.2 Ncm, while for the 10 mm implants was 42.4 ± 2.1 Ncm (table 1). Using a paired two-sample t-test, no significant difference between the average insertion torques was found (p=0.005) (Fig. 6). Most of the patients had D2 bone (88%), while fewer patients had class D1 (8 %) or D3 (4 %) bone.

DISCUSSION AND CONCLUSION Short implants should be used by experts with skillfull hands to avoid implant failures. The preliminary results of this study demonstrate that 4 mm long TiZr implants with an hydrophilic surface can be safely inserted in resorbed mandibles with insertion torques comparable to longer implants, thereby avoiding vertical augmentation procedures. Unlike the mandible (McGill Consensus meeting, Montreal, 2003), there is no consensus today regarding the number of implants for a maxillary overdenture. However, a recent systematic review revealed that a maxillary overdenture, supported by six implants, connected with a bar, is the most successful treatment regarding the survival of both the implants and the overdenture (6). Four additional extrashort implants, as proposed by the present study, implicate an additional cost, altought they may help the long implants, by increasing the stability of fixed resin pro-

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DoctorOs 牙医 Infodent International •3/2017

stheses, due to the wider spread of the implants within the arch. A second advantage might be that posterior bone resorption could be prevented, implicating less relinings of the prosthesis and avoiding mental nerve damage.

Pieri et al. suggested that even in quality IV bone, a successful treatment can be expected with two additional short implants, early loaded, supporting an overdenture (7). The lower bone quality/density in the posterior areas may be compensated by splinting of all implants with a cad-cam bar. The loading, in the present study, was avoided in the early stages and after the final restoration; moreover, unfrequent relining during the first weeks was performed to reduce crestal bone loss. Van Assche et al., studied the lack of information on the forces applied by different opposite arch conditions. Since the patient population of the study was limited, it was not possible to evaluate the influence of the applied forces of the opposing arch. They also showed that short implants can be a successful alternative to bone augmentation techniques for this treatment concept, also in type III or IV bone (8). The provision of short implant-supported prostheses in patients with atrophic alveolar ridges appears to be a successful treatment option in the short term; however, more scientific evidence is needed for the long term.

REFERENCES 1. Annibali S, Cristalli MP, Dell’Aquila D, Bignozzi I, La Monaca G, Pilloni A. Short dental implants: a systematic review. J Dent Res 2012;91(1):25-32.

2. Anitua E, Alkhraist MH, Piñas L, Begoña L, Orive G. Implant survival and crestal bone loss around extra-short implants supporting a fixed denture: the effect of crown height space, crown-to-implant ratio, and offset placement of the prosthesis. Int J Oral Maxillofac Implants 2014;29(3):682-689.

3. Grandin M, Berner S, Dard M. A review of titanium zirconium (TiZr) alloys for use in endosseous dental implants.

Materials, 2012, 5: 1348-1360.

4. Kim DG, Christopherson GT, Dong XN, Fyhrie DP, Yeni YN. The effect of microcomputed tomography scanning and reconstruction voxel size on the accuracy of stereological measurements in human cancellous bone. Bone 2004;35(6):1375-82.

5. Slotte C, Gronningsaeter A, Halmoy AM, Ohrnell LO, Stroh G, Isaksson S, Johansson LA, Mordenfeld A, Eklund J, Embring J. Four-millimeter implants supporting fixed partial dental prostheses in the severely resorbed posterior mandible: two-year results. Clin Implant Dent Rel Res 2011;14:46-58.

6. Slot W, Raghoebar GM, Vissink A, Huddleston Slater JJ, Meijer HJA. A systematic review of implant-supported maxillary overdentures after a mean observation period of at least 1 year. J Clin Periodontol 2010;37:98-110.

7. Pieri F, Aldini NN, Fini M, Marchetti C, Corinaldesi G. Immediate functional loading of dental implants supporting a bar-retainedmaxillary overdenture: preliminary 12-month results. J Periodontol 2009;80:1883-1893.

8. Van Assche N, Michels S, Quirynen M, Naert I. Extra short dental implants supporting an overdenture in the edentulous maxilla: a proof of concept. Clin Oral Impl Res 2012;23:567-576.

23

rd

International Expo

Guangzhou Top Dental inShow China 行业盛事博览牙科

4-7 April 2018

www.dentalsouthchina.com

DENTECH CHINA EXHIBITION

Shanghai, 25 – 28 October 2017 上海, 2017.10.25-28 Infodent International for DenTech China: the living magazine project Infodent International 为DenTech China开展互动杂志项目 During DenTech China 2017, Infodent International is proud to introduce a great experience for all visitors: the living magazine. Every year thousands of manufacturers and dealers are used to read Infodent International looking for connections and contents to improve their business.

Next October, for the first time, they can “live the pages”. 在 “第二十一届中国国际口腔器材展览会暨学术研讨会”(DenTech China 2017)召开期间， Infodent International将向所有观众推出一份互动杂志，将绝佳的体验带给大家。 每年有成千上万的生产商和经销商都习惯通过阅读Infodent International杂志， 寻找有助于拓展其业务的内容和商机。 今年10月，他们将在展会现场体验杂志互动项目。

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DoctorOs 牙医 Infodent International •3/2017

Contents:

How many times, after reading an article, you would like to ask something to its author? In DenTech China, finally, you can.

Three conferences will entertain the audience about the two main Infodent International topics: developing business and scientific subjects.

您有多少次在阅读完一篇文章后，希望作者能解答您的一 些疑问？ 在DenTech China 展会上，你就能实现这个愿望。 我们将召开三场研讨会，会议围绕Infodent International的 两个主要议题：业务拓展及新技术推介。

Distributors wall

(at the Entrance Hall): The distributors wall is a must-read for all companies worldwide, a paper meeting point where to find dealers and new job opportunities.

In DenTech China this wall will be real: a space continuously updated at the Infodent International booth to connect business and give our customers what they expect from their favourite magazine since 1994: the chance to improve.

Distributors Wall

是全球所有业内企业必读的一份刊物，该 刊物告诉大家到哪里寻找经销商,并提供新的工作机会。 在DenTech China展会上，我们将设立一面墙：在Infodent International主办方展台的空间里展示最新信息，帮助大家建 立业务联系，并让我们的客户从这份于1994 年创办的读者 喜闻乐见的杂志中得到想要的：改进的机会。

Company highlights: Infodent International提供信息

Infodent International booth will offer to all distributors visiting DenTech China the best selection of opportunities they are used to find in highlights pages.

Why do distributors visit a trade-show? For the same reason they read Infodent International: to discover the right companies in order to expand their business.

The selection of companies considered eligible involved in this project will contribute to the satisfaction both of our readers and of all DenTech China visitors.

Infodent International展台将向到访DenTech China展会的所有

分销商提供一份最佳商机信息汇编；以往，我们在展会杂 志的重点页面提供这些信息。为什么分销商会参加展会？ 是为了拓展自己的业务。他们阅读Infodent International杂志, 也是出于同样的原因。

DoctorOs 牙医 Infodent International •3/2017

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Save the date: the 27th October, 09:00-13:00, Infodent International is proud to invite you to a conference tailored to grow your business and knowledge.

Do not miss this experience and enjoy with the speakers a coffee break into the most attended conference in DenTech China. ®

记下日期: 2017年10月27日, 09.00-13.00 Infodent International 很荣幸为您介绍我们的三场研讨会。会议围绕 Infodent International 的两个主要议题: 业务拓展及新技术推介。 请大家千万不要错过在DenTech China的最广泛参与的会议的机会。 免费入场，休息时免费喝咖啡。

Main sponsor:

Sponsor:

EXHIBITION

November - December - January 2017 - 2018 NOVEMBER

NOVEMBER

Stockholm - Sweden 15-17/11/2017

New York City - USA 26-29/11/2017

Swedental 2017 - The Annual Dental Congress & Swedental Organised by Stockholm International Fairs Stockholmsmassan 125 80 Stockholm Sweden Phone:+46 8 749 41 00 Email: info@stockholmsmassan.se Venue: Stockholmsmassan Add: Massvagen 1 Alvsjo Stockholm Sweden

Greater New York Dental Meeting 2017 (GNYDM) - 93rd Annual Session Infodent Booth: 1004

www.swedental.org ..................................................................................................................................................

Lisboa - Portugal 16-18/11/2017

Expo-Dentaria 2017 - 26th Portuguese Dental Association Annual Meeting Ordem Dos Medicos Dentistas (Portuguese Dental Association) Av. Dr. Antunes Guimaraes, 463 4100-080 - Porto, Portugal Phone: +351 226 197 690 Fax: +351 226 197 699 Email: expodentariaportugal@omd.pt Website: www.omd.pt Venue: MEO Arena Lisbon, Portugal www.omd.pt

Greater New York Dental Meeting 570 7th Avenue, Suite 800 New York, NY 10018 Tel: +1 212 398 6922 Fax +1 212 398 6934 E-mail: info@gnydm.com Website: www.gnydm.com Referent: Dr. Robert R. Edwab (Executive Director) E-mail: execdirector@gnydm.com Exhibits Manager: Ms. Carla M. Borg E-mail: exhibits@gnydm.com Exhibition venue: Jacob K. Javits Convention Center 655 West 34th Street, New York, NY 10001, USA www.gnydm.com DoctorOs 牙医 Infodent International •3/2017

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EXHIBITION DECEMBER

DECEMBER

Paris - France 28/11-02/12/2017

Addis Ababa - Ethiopia 14-16/12/2017

ADF 2017 - The French Dental Association Annual Meeting

IDEA 2017 - Ethiopia - 3rd International Exhibition Africa - Medical & Pharmaceutical Show Infodent Booth: 39 Organised by: Promunidi Srl Viale E. Forlanini, 23 - 20134 Milano Phone: +39 02 7006121 Fax: +39 02 70006546 Email: info@idea-africa.com Website: www.idea-africa.com Venue: Conference Center UNECA Addis Abeba, Ethiopia www.idea-africa.com

Association Dentaire Francaise 7 rue Mariotte 75 017 Paris France Phone: +33 1 58 22 17 10 Fax: +33 1 58 22 17 40 Website: www.adf.asso.fr Venue: Palais des Congrès Add: 2 place de la Porte Maillot 75017 Paris - France www.adfcongres.com/en ..................................................................................................................................................

Hanoi - Vietnam 06-08/12/2017

Vietnam Medi-Pharm 2017 - Hanoi - The 24th International Hospital, Medical and Pharmaceutical Exhibition in Hanoi Organizer: Vietnam National Trade Fair & Advertising Company - VINEXAD 9 Dinh Le, Hoan Kiem, Ha Noi Phone: +84 4 3855 5546 / 3934 0474 Fax: +84 4 3825 5556 Email: medipharmexpo@vinexad.com.vn Venue: Hanoi International Exhibition Center (ICE) Add: 91 Tran Hung Dao Str., Hoan Kiem Dist.

Hanoi - Vietnam www.vinexad.com.vn

62

DoctorOs 牙医 Infodent International •3/2017

..................................................................................................................................................

JANUARY Cairo - Egypt 24-27/01/2018

ACDI 2018 - ADE 2018 The 2nd African Congress of Dentistry and Implantology - The 2ndAfrican Dental Expo Oraganised by: African Society of Dentistry Address: 2, rue Ben Aïcha, Guéliz Marrakech, 40000, Morocco Phone: +212 524 430 984 Email: africansocietyofdentistry@gmail.com Venue: Hotel InterContinental Cairo Citystars www.acdi2018.com

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® contents In this Issue

Contents 目录

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in partnership with:

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Editorial

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n° 3/2017

The 1

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25 Extrusion of severely impacted mandibular first molar using partial orthodontics and temporary anchorage miniscrews

严重下颌骨萎缩的即时修复

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Anthos..............................................................................................................53 Cover page Rehabilitation with immediate loading of the severely My Ray (Cefla Group) Ariesdue & Infodent International............................................III cover Via Bicocca 14/C - 140026 Imola (BO)A- Italy atrophic mandible. case reportCastellini............................................................................................................2 imaging@my-ray.com Dental South China 2018.......................................................................57 Tel. +39 0542 653441 DenTech China 2018...................................................................................9 www.my-ray.com Expodental Meeting 2018.............................................................II cover

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scanning microscopy analysis of a case

China Contact 中国区联系方 TNI CHINA 42 天诺中国 地址: 北京市朝阳区双桥合美国际大厦A座18层 Clinical results 联系电话 +86 10 5266 5712 in reconstruction 邮箱 info@tnimed.com

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Odontomas in developmental age: confocal laser scanning microscopy analysis of a case 用局部正畸法临时锚固微螺丝导萌严重阻生 的右下颌第一磨牙

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Immediate implants in extraction sockets with periapical lesions: an illustrated review

牙窝根尖周变病的即刻种植: 一篇有插图说明的述评

24/07/17 10:29

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Topnova Publisher Ariesdue srl Newsroom Infodent srl Topnova info@ariesdue.it Newsroom Advertising info@ariesdue.it

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Volume of the entire dental arch and innovative Extended View function with low X-ray exposure.

Extend your view

DoctorOs 牙医 Infodent International •3/2017 Doctor Os 牙医 Infodent International •2/2017

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Doctor OS is the journal for the dentist general practitioner, and is appreciated for its clear and documented approach to scientific and professional topics, for the quality of its updating and the timeliness of information.

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dentistry

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EUROPEAN JOURNAL OF

VOL. 17 - N° 3 - SEPTEMBER 2016

DOCTOR OS

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PAEDIATRIC DENTISTRY JOURNAL OF THE ITALIAN SOCIETY OF PAEDIATRIC DENTISTRY (SIOI)

v e r s i o n e i ta l i a n a

Volume

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Printed Italian version.

issn 2036-413x OTTOBRE 2015 n. 3 vOl. 7 www.journalofosseointegration.eu

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1.800 copies European Journal of Paediatric Dentistry is the official publication in English language of SIOI (Società Italiana di Odontoiatria Infantile), listed in Medline and in the Journal Citation Report (Impact factor). paediatric dentistry

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