ß-TCP & R.T.R. - Septodont · placement. Immediate implant placement and postextraction alveolar preservation are 2 methods that are used to prevent significant postextraction bone

A selection of scientific studiesand clinical cases

December 2014

ß-TCP & R.T.R.

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CONTENT

1. Abstracts of scientific studies on beta tricalcium phosphate and R.T.R. in bone regeneration .............................................................................................................................................. 3

• Extraction socket preservation – 7 abstracts ..................................................................................... 4 • Periodontal defects – 6 abstracts ................................................................................................................ 8 • Bone augmentation – 5 abstracts ............................................................................................................ 12 • Immediate implants – 2 abstracts ............................................................................................................ 16 • Other applications in dental – 8 abstracts ......................................................................................... 18 • Non dental applications – 6 abstracts ................................................................................................... 22 • In vitro studies – 2 abstracts ........................................................................................................................ 26

2. Full articles of scientific studies & clinical cases on R.T.R. ............................................. 28

• Extraction socket preservation – 2 articles ........................................................................................ 29 • Periodontal defects – 2 articles .................................................................................................................. 45 • Bone augmentation – 2 articles .................................................................................................................. 55 • Multi- indications – 3 articles ....................................................................................................................... 59

3. R.T.R. technical specifications ................................................................................................................... 85

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1. ABSTRACTS OF SCIENTIFIC STUDIES

ON BETA TRICALCIUM PHOSPHATE

AND R.T.R. IN BONE REGENERATION

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EXTRACTION SOCKET PRESERVATION – 7 ABSTRACTS

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 Apr;16(2):581-90. doi: 10.1007/s00784-011-0531-1. Epub 2011Mar 3 Brkovic BM1, Prasad HS, Rohrer MD, Konandreas G, Agrogiannis G, Antunovic D, Sándor GK. Abstract The aim of this study was to investigate the healing of human extraction sockets filled with β-tricalcium phosphate and type I collagen (β-TCP/Clg) cones with or without a barrier membrane. Twenty patients were divided in two groups: (A) β-TCP/Clg non-membrane and (B) β-TCP/Clg + barrier membrane. Clinical examination and biopsies from the grafted sites were collected 9 months later. Bone samples were analyzed using histomorphometry and immunohistochemistry. The horizontal dimension of the alveolar ridge was significantly reduced 9 months after socket preservation in the non-membrane group. There was bone formation with no significant differences between the two groups in the areas occupied by new bone (A = 42.4%; B = 45.3%), marrow (A = 42.7%; B = 35.7%), or residual graft (A = 9.7%; B = 12.5%). Immunohistochemistry revealed osteonectin expression in both groups. Both groups demonstrated sufficient amounts of vital bone and socket morphology to support dental implant placement after the 9-month healing period. A future trial to evaluate the alveolar outcomes at an earlier 6-month time point rather than the 9 months used in this study would be of interest. Key message: The placement of a cone of beta-TCP with type I collagen in a post-extraction socket resulted in a healed bone able to support implant placement after a 9-month period, whether combined with a membrane or not.

Clinical evaluation alveolar ridge preservation with a beta-tricalcium phosphate socket graft. Compend Contin Educ Dent. 2009 Nov-Dec;30(9):588-90, 592, 594 passim; quiz 604, 606. Horowitz RA1, Mazor Z, Miller RJ, Krauser J, Prasad HS, Rohrer MD. Abstract PURPOSE: To determine the efficacy of an alloplastic graft material, consisting of a pure-phase beta-tricalcium phosphate (beta-TCP), in the preservation of ridge volume after tooth extraction and before dental implant placement. Histomorphometric analysis was completed on a few samples to determine the percentage of vital bone over a fixed healing period. MATERIALS AND METHODS: Patients requiring tooth extraction and bone regeneration before implant placement were included in this study. Measurements of alveolar width were made at the time of extraction and the time of implant placement. The extraction sites were grafted with a pure-phase beta-TCP and covered with a barrier. Approximately 6 months after surgery, the sites were reentered for implant placement. Cores were taken of the regenerated material for histologic

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analysis, with a trephine used as the first bur in preparation for some of the osteotomies. Implants were placed according to the manufacturers' recommendations and loaded at the appropriate time. RESULTS: The beta-TCP placed at the time of grafting extraction sockets was well tolerated in all sites with all of the barriers used. There were no incidences of postoperative infection or graft rejection. At the time of implant placement, much of the graft material had resorbed and been converted to vital alveolar bone. The implant recipient sites were dense and supported placement of endosseous dental implants that were fully stable. The width of the extraction sockets was preserved to 91% of the preoperative width. CONCLUSIONS: Extraction socket grafting with the pure-phase beta-TCP tested in this study and covered with either a resorbable collagen or dense polytetrafluoroethylene barrier is a predictable method for preserving alveolar dimensions. The graft material resorbs to a high percentage in the timeframe desired between extraction and dental implant placement, as shown clinically, radiographically, and histologically. In addition, the regenerated material in the socket has enough density to support implant placement with subsequent loading in the 4- to 6-month period used in this study. Key message: The use of β-TCP in extraction sockets covered with a resorbable or a dense membrane allowed the preservation of alveolar dimensions and at 6 months implants could be placed. β-TCP was well tolerated by the tissue whatever the barrier used. 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 Jul-Aug;74(6):523-8. Brkovic BM1, Prasad HS, Konandreas G, Milan R, Antunovic D, Sándor GK, Rohrer MD. Abstract Alveolar atrophy following tooth extraction remains a challenge for future dental implant placement. Immediate implant placement and postextraction alveolar preservation are 2 methods that are used to prevent significant postextraction bone loss. In this article, we report the management of a maxillary tooth extraction socket using an alveolar preservation technique involving placement of a cone of beta-tricalcium phosphate (beta -TCP) combined with type I collagen without the use of barrier membranes or flap surgery. Clinical examination revealed solid new bone formation 9 months after the procedure. At the time of implant placement, histomorphometric analysis of the biopsied bone showed that it contained 62.6% mineralized bone, 21.1% bone marrow and 16.3% residual beta -TCP graft. The healed bone was able to support subsequent dental implant placement and loading. Key message: In this case report, a cone of beta-TCP with type I collagen used without a membrane in extraction socket resulted in solid and mineralized new bone formation at 9 months, allowing implant placement and loading.

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Tricalcium phosphate ceramic as immediate root implants for the maintenance of alveolar bone in partially edentulous mandibular jaws. A clinical study. Mathai JK, Chandra S, Nair KV, Nambiar KK. Aust Dent J. 1989 Oct;34(5):421-6. Abstract This study was undertaken to probe the efficacy of tricalcium phosphate ceramic (TCP) as an immediate root implant in the maintenance of alveolar bone. Three patients had five TCP root implants placed in fresh extraction sockets with soft tissue closure. The control and implant areas were evaluated at the 20th and 78th week on the basis of radiographic and clinical measurements. Tricalcium phosphate ceramic root implants in extraction sockets produced a significant increase in height and width of alveolar bone compared with control sites. It is believed that this method is a more effective and efficient procedure to preserve alveolar bone for the retention of dentures than other methods. Key message: This clinical trial displayed that the use of β-TCP for the preservation of extraction sockets showed a significant increase in alveolar bone dimensions, which could be an effective method for denture retention. Impact of different synthetic bone fillers on healing of extraction sockets: an experimental study in dogs. Clin Oral Implants Res. 2014 Feb;25(2):e30-7. doi: 10.1111/clr.12041. Epub 2012 Sep 13. Hong JY1, Lee JS, Pang EK, Jung UW, Choi SH, Kim CK. Abstract OBJECTIVES: The objective of this study was to elucidate the socket healing process and biodegradation of incorporating synthetic bone fillers followed by grafting of the fresh extraction socket. MATERIALS AND METHODS: Third premolars in four quadrants of eight beagle dogs were extracted and randomly treated with either one of hydroxyapatite (HA), biphasic calcium phosphate (BCP), β-tricalcium phosphate (β-TCP), or no graft (C). Histologic observations and histomorphometric analysis at three zones (apical, middle, and coronal) of the socket were performed. Socket area (S) and the proportions of newly formed bone (%NB), residual biomaterials (%RB), and fibrovascular connective tissue (%FCT) at 2, 4, and 8 weeks were measured. The numbers of osteoclast-like multinucleated cells (No.OC) were also determined at the three zones. RESULTS: %NB was significantly higher in control group compared with the grafted groups at all healing periods. %NB of HA and BCP increased with time, whereas %RB showed different patterns that decreased in BCP, unlike the minimal change observed in HA. %NB of β-TCP showed smallest portion compared with other grafted groups at 2 and 4 weeks, however, significantly increased at 8 weeks. %RB of β-TCP was less than HA and BCP at all healing periods. Numbers of multinucleated cells were greater in BCP and β-TCP, followed by HA and smallest in control group. CONCLUSIONS: Within the limit of this study, bone formation of the extraction socket was delayed in the sockets grafted with synthetic bone fillers and showed different healing process according to the biodegradation patterns.

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Key message: In this preclinical study, β-TCP used in post-extraction sockets showed a significant increase in newly formed bone and in biodegradation at 8 weeks, with a lower proportion of residual materials than Hydroxyapatite and Biphasic Calcium Phosphate. Application of a new material (β-TCP/collagen composites) in extraction socket preservation: an experimental study in dogs. Int J Oral Maxillofac Implants. 2013 Mar-Apr;28(2):444-52. doi: 10.11607/jomi.2794. Takahashi Y1, Marukawa E, Omura K. Abstract PURPOSE: A bone defect model simulating an extraction socket with buccal dehiscence was designed to investigate the usefulness of a composite of beta-tricalcium phosphate (β-TCP) and a collagen sponge, β-TCP/collagen (TCP/Col) for socket preservation. MATERIALS AND METHODS: Following the extraction of the maxillary second and third premolars of 13 beagle dogs, a bone defect with buccal dehiscence (5 × 3 × 7 mm) was prepared. The defects were filled with either TCP/Col, β-TCP, collagen, or left intact (control) and evaluated at 4 and 8 weeks after surgery. A total of three micro-computed tomography (micro-CT) images were selected, and the area size occupied by the newly formed bone and residual TCP was measured. Newly formed bone and residual TCP in the bone defect site of the specimens was also measured and evaluated. RESULTS: No evidence of postoperative infection was found in all cases. At 4 weeks after surgery, the TCP granule was retained in the bone defects and active bone formation was observed in the TCP/Col group and the β-TCP group, whereas in the collagen and the control groups, connective tissue grew into the defect. In the TCP/Col and β-TCP groups, morphologically well-preserved alveolar ridges were observed; most TCP granules grafted in the defects were resorbed and only a few residuals were evident at 8 weeks after surgery. CONCLUSIONS: These results exhibited that the TCP/Col composites could sufficiently maintain bone width and height for the preservation of the extraction socket with buccal dehiscence while preventing epithelial in-growth. In addition, TCP/Col in an easily handled spongeous form could provide a better intraoral manipulation capability than TCP granules alone and was considered to be suitable as a bone grafting material used for alveolar ridge preservation. Key message: In this preclinical study, all materials were well tolerated. The use of β-TCP and composites of β-TCP/Collagen resulted in active bone formation for the preservation of extractions sockets with buccal dehiscence, with only few residuals observed at 8 weeks, while preventing epithelial in-growth. beta-Tricalcium phosphate in the early phase of socket healing: an experimental study in the dog. Clin Oral Implants Res. 2010 Apr 1;21(4):445-54. doi: 10.1111/j.1600-0501.2009.01876.x. Araújo MG1, Liljenberg B, Lindhe J. Abstract OBJECTIVES:

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The aim of this experiment was to analyze processes involved in the incorporation of beta-tricalcium phospate (TCP) particles in host tissue during healing following tooth extraction and grafting. MATERIAL AND METHODS: Five beagle dogs were used. Four premolars in the maxilla ((3)P(3), (2)P(2)) were hemi-sected, the distal roots were removed and the fresh extraction socket filled with TCP. The tooth extraction and grafting procedures were scheduled in such a way that biopsies representing 1 and 3 days, as well as 1, 2, and 4 weeks of healing could be obtained. Tissue elements such as cells, fibers, vessels, leukocytes and mineralized bone were determined. In deparaffinized sections structures and cells that expressed Tratarate resistant acid phosphate, alkaline phosphatase, and osteopontin were identified by the use of markers. RESULTS: The porosities of the TCP particles were initially filled with erythrocytes that subsequently were replaced with mineralized bone. Some of the graft material was invaded by mesenchymal and inflammatory cells and disintegrated. Thus, small membrane bound granules appeared in the granulation tissue and the provisional matrix. In the process of hard tissue formation, partly mineralized (modified) TCP particles became surrounded by ridges of woven bone. CONCLUSIONS: It was demonstrated that the early healing of an extraction socket that had been grafted with beta-TCP involved (i) the formation of a coagulum that was (ii) replaced with granulation tissue and a provisional matrix in which (iii) woven bone could form. In this process the biomaterial was apparently involved. Key message: In the early healing of an extraction socket filled with β-TCP, the process of hard tissue formation through the presence of ridges of woven bone around the particles could be observed. The bone formation is strongly correlated with the porosity of material which induces the coagulum process.

PERIODONTAL DEFECTS – 6 ABSTRACTS Comparative evaluation of clinical efficacy of β-tricalcium phosphate (Septodont–RTR)™ alone and in combination with platelet rich plasma for treatment of intrabony defects in chronic periodontitis Jyostna Pinipe, Narendra Babu Mandalapu, Sesha Reddy Manchala, Satheesh Mannem, N.V.S. Sruthima Gottumukkala, and Suneetha Koneru J Indian Soc Periodontol. 2014 May-Jun; 18(3): 346–351. Abstract Aim: To assess the clinical outcome by comparing β-tri calcium phosphate (Septodont RTR)™ along with platelet rich plasma (PRP) and β-tri calcium phosphate (β-TCP) alone in intrabony defects, by clinical evaluation in a 6-month analysis. Methodology: Ten patients participated in the study. Using a split-mouth design, interproximal bony defects were surgically treated with either platelet rich plasma (PRP) combined with β-tri calcium

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phosphate (β-TCP) or β-TCP alone. Plaque Index (PI), Gingival Index, Probing Pocket Depth (PPD), Clinical Attachment Level (CAL) were recorded 6 months after surgery. Results: At 6 months after therapy, the PRP combined with β-TCP group showed mean PPD reduction of 2.50, CAL mean gain of 2.60 + 1.43. The β-TCP group showed mean PPD reduction of 2.80 mm, mean CAL gain of 2.60 mm. On intra-group comparison, there was greater PPD reduction and CAL gain at 6 months in both the groups. In intergroup comparison of PRP/β-TCP and β-TCP alone, there was no statistical significant difference observed. (P = 0.55, and 0.87 for PPD and CAL gain). Conclusion: Both therapies resulted in significant PPD reduction, CAL gain. The present study shows that treatment of intrabony periodontal defects with combination of PRP and β-TCP does not have additional improvements when compared with β-TCP alone within 6 months follow-up. Key message: β-TCP treatment of intrabony defects showed significant reduction in depth of probing pocket at 6 months, either combined with PRP or alone. Ten-year results following treatment of intrabony defects with an enamel matrix protein derivative combined with either a natural bone mineral or a β -tricalcium phosphate. J Periodontol. 2013 Jun;84(6):749-57. doi: 10.1902/jop.2012.120238. Epub 2012 Aug 8. Döri F1, Arweiler NB, Szántó E, Agics A, Gera I, Sculean A. Abstract BACKGROUND: The purpose of the present study is to evaluate the 10-year results following treatment of intrabony defects treated with an enamel matrix protein derivative (EMD) combined with either a natural bone mineral (NBM) or β-tricalcium phosphate (β-TCP). METHODS: Twenty-two patients with advanced chronic periodontitis and displaying one deep intrabony defect were randomly treated with a combination of either EMD + NBM or EMD + β-TCP. Clinical evaluations were performed at baseline and at 1 and 10 years. The following parameters were evaluated: plaque index, bleeding on probing, probing depth, gingival recession, and clinical attachment level (CAL). The primary outcome variable was CAL. RESULTS: The defects treated with EMD + NBM demonstrated a mean CAL change from 8.9 ± 1.5 mm to 5.3 ± 0.9 mm (P <0.001) and to 5.8 ± 1.1 mm (P <0.001) at 1 and 10 years, respectively. The sites treated with EMD + β-TCP showed a mean CAL change from 9.1 ± 1.6 mm to 5.4 ± 1.1 mm (P <0.001) at 1 year and 6.1 ± 1.4 mm (P <0.001) at 10 years. At 10 years two defects in the EMD + NBM group had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. In the EMD + β-TCP group three defects had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. Compared with baseline, at 10 years, a CAL gain of ≥3 mm was measured in 64% (i.e., seven of 11) of the defects in the EMD + NBM group and in 82% (i.e., nine of 11) of the defects in the EMD + β-TCP group. No statistically significant differences were found between the 1- and 10-year values in either of the two groups. Between the treatment groups, no statistically significant differences in any of the investigated parameters were observed at 1 and 10 years. CONCLUSION:

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Within their limitations, the present findings indicate that the clinical improvements obtained with regenerative surgery using EMD + NBM or EMD + β-TCP can be maintained over a period of 10 years. Key message: The use of β-TCP in combination with an Enamel Matrix Derivative improved the clinical gain attachment in 82 % of treated patients within a long period of follow up (10 years). Evaluation of the relative efficacy of autologous platelet-rich plasma in combination with β-tricalcium phosphate alloplast versus an alloplast alone in the treatment of human periodontal infrabony defects: a clinical and radiological study Indian J Dent Res. 2011 Jan-Feb;22(1):107-15. doi: 10.4103/0970-9290.80008. Saini N1, Sikri P, Gupta H. Abstract BACKGROUND: Platelet-rich plasma (PRP) contains high levels of polypeptide growth factors that may enhance periodontal regeneration when combined with graft materials. AIM: The purpose of this study was to compare the efficacy of autologous PRP in combination with β-tricalcium phosphate (β-TCP) versus β-TCP alone in the treatment of human infrabony defects. MATERIALS AND METHODS: Using a split-mouth design, 20 patients showing clinical evidence of almost identical bilateral infrabony defects were randomly selected. The right infrabony defects of the patient were designated as Group A and treated by the placement of β-TCP alone. The left infrabony defects of the same patient were designated as Group B and treated by the placement of PRP mixed with β-TCP. Clinical assessment of probing pocket depth and attachment level and radiographic evaluation of the defect depth were done preoperatively and at 12, 24 and 36 weeks postoperatively. The relative efficacy of two treatment modalities was evaluated using paired Student's t-test and the comparative evaluation between the two groups was done using independent Student's t-test. RESULTS: Both the groups exhibited a highly significant reduction in probing pocket depth, gain in clinical attachment level and linear bone fill at the end of 36 weeks postoperatively. Comparative evaluation between the two study groups revealed a significant reduction in probing pocket depth (P = 0.036FNx01), mean gain in clinical attachment level (P = 0.042FNx01) and linear bone fill (P = 0.014FNx01) in Group B as compared to Group A. CONCLUSIONS: Combination of PRP and β-TCP led to a significantly more favorable clinical and radiographic improvement in infrabony periodontal defects. Key message: β-TCP showed enhanced results in regeneration of infrabony defects at 9 months when combined with platelet rich plasma. Nevertheless, β-TCP alone increased clinical attachment, filled bone and reduced pocket depth in the patients followed during 36 weeks.

phosphate (β-TCP) or β-TCP alone. Plaque Index (PI), Gingival Index, Probing Pocket Depth (PPD), Clinical Attachment Level (CAL) were recorded 6 months after surgery. Results: At 6 months after therapy, the PRP combined with β-TCP group showed mean PPD reduction of 2.50, CAL mean gain of 2.60 + 1.43. The β-TCP group showed mean PPD reduction of 2.80 mm, mean CAL gain of 2.60 mm. On intra-group comparison, there was greater PPD reduction and CAL gain at 6 months in both the groups. In intergroup comparison of PRP/β-TCP and β-TCP alone, there was no statistical significant difference observed. (P = 0.55, and 0.87 for PPD and CAL gain). Conclusion: Both therapies resulted in significant PPD reduction, CAL gain. The present study shows that treatment of intrabony periodontal defects with combination of PRP and β-TCP does not have additional improvements when compared with β-TCP alone within 6 months follow-up. Key message: β-TCP treatment of intrabony defects showed significant reduction in depth of probing pocket at 6 months, either combined with PRP or alone. Ten-year results following treatment of intrabony defects with an enamel matrix protein derivative combined with either a natural bone mineral or a β -tricalcium phosphate. J Periodontol. 2013 Jun;84(6):749-57. doi: 10.1902/jop.2012.120238. Epub 2012 Aug 8. Döri F1, Arweiler NB, Szántó E, Agics A, Gera I, Sculean A. Abstract BACKGROUND: The purpose of the present study is to evaluate the 10-year results following treatment of intrabony defects treated with an enamel matrix protein derivative (EMD) combined with either a natural bone mineral (NBM) or β-tricalcium phosphate (β-TCP). METHODS: Twenty-two patients with advanced chronic periodontitis and displaying one deep intrabony defect were randomly treated with a combination of either EMD + NBM or EMD + β-TCP. Clinical evaluations were performed at baseline and at 1 and 10 years. The following parameters were evaluated: plaque index, bleeding on probing, probing depth, gingival recession, and clinical attachment level (CAL). The primary outcome variable was CAL. RESULTS: The defects treated with EMD + NBM demonstrated a mean CAL change from 8.9 ± 1.5 mm to 5.3 ± 0.9 mm (P <0.001) and to 5.8 ± 1.1 mm (P <0.001) at 1 and 10 years, respectively. The sites treated with EMD + β-TCP showed a mean CAL change from 9.1 ± 1.6 mm to 5.4 ± 1.1 mm (P <0.001) at 1 year and 6.1 ± 1.4 mm (P <0.001) at 10 years. At 10 years two defects in the EMD + NBM group had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. In the EMD + β-TCP group three defects had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. Compared with baseline, at 10 years, a CAL gain of ≥3 mm was measured in 64% (i.e., seven of 11) of the defects in the EMD + NBM group and in 82% (i.e., nine of 11) of the defects in the EMD + β-TCP group. No statistically significant differences were found between the 1- and 10-year values in either of the two groups. Between the treatment groups, no statistically significant differences in any of the investigated parameters were observed at 1 and 10 years. CONCLUSION:

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Evaluation of β-tricalcium phosphate in human infrabony periodontal osseous defects: a clinical study. Quintessence Int. 2011 Apr;42(4):291-300. Chawla K1, Lamba AK, Faraz F, Tandon S. Abstract OBJECTIVE: To evaluate the efficacy of β-tricalcium phosphate (β-TCP) (Synthograft, Bicon USA) in periodontal osseous defects in comparison to open flap debridement (OFD). METHOD AND MATERIALS: Twelve patients showing clinical and radiographic evidence of almost identical bilateral infrabony defects were selected. The infrabony defects in the 12 patients were treated with OFD+β-TCP on one side and OFD on the other side. Clinical evaluation was performed at baseline and 6 months following therapy. RESULTS: No differences in probing depth (PD) reduction or clinical attachment level (CAL) gain were observed, although a statistically significant difference was observed for the defect fill between the two groups. Six months after therapy, sites treated with OFD+β-TCP showed a reduction in mean PD from 9.67 ± 2.35 mm to 4.00 ± 1.60 mm (P < .05), a change in mean CAL from 9.92 ± 3.15 mm to 5.00 ± 3.86 mm (P < .05), and the mean defect fill was 2.92 ± 0.90 mm. In the sites treated with only OFD, the mean PD was reduced from 7.58 ± 1.08 mm to 2.67 ± 0.65 mm (P < .05), the mean CAL changed from 6.83 ± 1.34 mm to 1.83 ± 1.64 mm (P < .05), and the mean defect fill was 0.83 ± 0.39 mm. Reduction of 5 mm in PD was observed in 5 of the 12 defects (42%); 4 of the 12 defects (33%) gained 3 mm of CAL in the test sites. PD reductions and CAL gains of 3 to 6 mm were measured in the majority of the cases (60% to 75%) regardless of treatment modality. CONCLUSION: Within the constraints of this study, both therapies resulted in significant PD reductions and CAL gains 6 months after surgery. Sites treated with OFD+β-TCP showed a significant defect fill compared to those treated with OFD alone. Key message: Placing β-TCP after open flap debridement allowed periodontal regeneration at 6 months and resulted in significant defect fill when compared to open flap debridement alone. Bone formation in tricalcium phosphate-filled periodontal intrabony lesions. Histological observations in humans. Saffar JL1, Colombier ML, Detienville R. J Periodontol. 1990 Apr;61(4):209-16. Abstract The capacity of a tricalcium phosphate (TCP) ceramic to promote bone formation after grafting in intrabony defects was studied in humans. Five biopsies were collected from 4 patients during reentry surgery 16 to 40 months after implantation. They were processed without demineralization for histological examination. In the less mature samples, the grafted material was surrounded by a highly fibrous, highly cellular, and poorly vascularized connective tissue. Howship's lacuna-like cavities were clearly visible at the surface of the material. They contained resorbing mononuclear phagocytes. At a more mature stage, TCP granules were embedded in an a cellular fibrous material which underwent mineralization

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from the medullary spaces towards the granules. The bone formed was subsequently remodeled. The implanted material itself was progressively modified. It first acquired the staining appearance of bone. After its structure became loose and vacuolated, it was invaded by cells and vessels. The present data indicate that TCP has osteogenic potential and is subject to degradation. Unlike in experimental wounds, these processes are of long duration in human defects. Key message: The use of β-TCP in periodontal defects showed osteogenic potential and bioresorbable properties. A comparison of iliac marrow and biodegradable ceramic in periodontal defects. Levin MP, Getter L, Cutright DE. J Biomed Mater Res. 1975 Mar;9(2):183-95. Abstract Defects were created in the tooth-supporting bone of six beagle dogs. Biodegradable tricalcium phosphate was compared to cancellous marrow as a treatment method. The findings indicated that ankylosis and resorption of the tooth can occur when using marrow. The ceramic-filled defects healed slower; but the material itself was well tolerated by the tissues, initiated new bone formation, filled in the defect, and has good potential for the treatment of advanced periodontitis. Key message: β-TCP was well tolerated by the tissues and improved bone defects.

BONE AUGMENTATION – 5 ABSTRACTS Maxillary sinus floor grafting with beta-tricalcium phosphate in humans: density and microarchitecture of the newly formed bone. Clin Oral Implants Res. 2006 Feb;17(1):102-8. Suba Z1, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Abstract OBJECTIVES: Graft insertion can effectively enhance the regeneration of debilitated bone. The effects of an alloplastic bone-replacing material, beta-tricalcium phosphate (Cerasorb), and of autogenous bone graft were compared. MATERIALS AND METHODS: In 17 edentulous patients, the maxillary sinus floor was extremely atrophied to such an extent that implant placement was impossible. The Schneiderian membrane was surgically elevated bilaterally by insertion of Cerasorb (experimental side) and autogenous bone graft (control side). After surgery, the recovery was followed clinically and radiologically. After 6 months, 68 bone cylinders were excised from the grafted areas and implants were inserted into their places. The bone samples were embedded into resin, and the osteointegration of the grafts was studied histologically. Trabecular bone volume (TBV) and trabecular bone pattern factor (TBPf) were quantified by histomorphometry. RESULTS:

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Cerasorb proved to be an effective bone-replacing material with osteoconductivity; it was capable of gradual disintegration, thereby providing space for the regenerating bone. The new bone density was not significantly different on the experimental and control sides (32.4+/-10.9% and 34.7+/-11.9%, respectively). However, the graft biodegradation was significantly slower on the experimental side than the control side. The TBPf value was lower on the control side than on the experimental side (-0.53+/-1.7 and -0.11+/-1.4 mm(-1), respectively), but this difference was not significant. CONCLUSIONS: Six months after insertion of the grafts, the bone of the augmented sinus floor was strong and suitable for anchorage of dental implants, irrespective of whether autogenous bone or Cerasorb particles had been applied. Key message: β-TCP used in sinus floor elevation showed osteoconductivity and a new bone density similar to autogenous bone grafting was observed at 6 months, allowing implant placement. 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 May-Jun;20(3):371-81. Szabó G1, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabás J, Németh Z, Hrabák K, Suba Z. Abstract PURPOSE: Two different graft materials, beta-tricalcium phosphate (Cerasorb) and autogenous bone, were used in the same patient. The objective was to determine whether donor site morbidity could be avoided by using pure-phase beta-tricalcium phosphate (Cerasorb). MATERIALS AND METHODS: Bilateral sinus grafting was performed on 20 selected patients; Cerasorb was used on the experimental side, and autogenous bone was used on the control side. In each patient, one side was randomly designated the experimental side. In 10 of the 20 patients, the maxilla reconstruction included sinus grafting and onlay bone grafting. Implants were placed 6 months after the procedure. In addition to routine panoramic radiographs, in 10 of the 20 patients, 2- and 3-dimensional computerized tomographic examinations were performed pre- and postoperatively and after implantation. Eighty bone biopsy specimens were taken at the time of implant placement. RESULTS: Histologically and histomorphometrically, there was no significant difference between the experimental and control grafts in terms of the quantity and rate of ossification. For each histologic sample, the total surface area, the surface area that consisted of bone, and the surface area that consisted of graft material were measured in mm2, and bone and graft material were analyzed as percentages of the total. The mean percentage bone areas were 36.47% +/- 6.9% and 38.34% +/- 7.4%, respectively; the difference was not significant (P = .25). DISCUSSION AND CONCLUSION: Comparisons with other studies reveal that beta-tricalcium phosphate (Cerasorb) is a satisfactory graft material, even without autogenous bone.

from the medullary spaces towards the granules. The bone formed was subsequently remodeled. The implanted material itself was progressively modified. It first acquired the staining appearance of bone. After its structure became loose and vacuolated, it was invaded by cells and vessels. The present data indicate that TCP has osteogenic potential and is subject to degradation. Unlike in experimental wounds, these processes are of long duration in human defects. Key message: The use of β-TCP in periodontal defects showed osteogenic potential and bioresorbable properties. A comparison of iliac marrow and biodegradable ceramic in periodontal defects. Levin MP, Getter L, Cutright DE. J Biomed Mater Res. 1975 Mar;9(2):183-95. Abstract Defects were created in the tooth-supporting bone of six beagle dogs. Biodegradable tricalcium phosphate was compared to cancellous marrow as a treatment method. The findings indicated that ankylosis and resorption of the tooth can occur when using marrow. The ceramic-filled defects healed slower; but the material itself was well tolerated by the tissues, initiated new bone formation, filled in the defect, and has good potential for the treatment of advanced periodontitis. Key message: β-TCP was well tolerated by the tissues and improved bone defects.

BONE AUGMENTATION – 5 ABSTRACTS Maxillary sinus floor grafting with beta-tricalcium phosphate in humans: density and microarchitecture of the newly formed bone. Clin Oral Implants Res. 2006 Feb;17(1):102-8. Suba Z1, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Abstract OBJECTIVES: Graft insertion can effectively enhance the regeneration of debilitated bone. The effects of an alloplastic bone-replacing material, beta-tricalcium phosphate (Cerasorb), and of autogenous bone graft were compared. MATERIALS AND METHODS: In 17 edentulous patients, the maxillary sinus floor was extremely atrophied to such an extent that implant placement was impossible. The Schneiderian membrane was surgically elevated bilaterally by insertion of Cerasorb (experimental side) and autogenous bone graft (control side). After surgery, the recovery was followed clinically and radiologically. After 6 months, 68 bone cylinders were excised from the grafted areas and implants were inserted into their places. The bone samples were embedded into resin, and the osteointegration of the grafts was studied histologically. Trabecular bone volume (TBV) and trabecular bone pattern factor (TBPf) were quantified by histomorphometry. RESULTS:

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Key message: In this randomized controlled trial, the use of β-TCP in sinus grafting showed ossification results similar to those obtained with autogenous bone. Maxillary sinus floor augmentation using a beta-tricalcium phosphate (Cerasorb) alone compared to autogenous bone grafts. Int J Oral Maxillofac Implants. 2005 May-Jun;20(3):432-40. Zijderveld SA1, Zerbo IR, van den Bergh JP, Schulten EA, ten Bruggenkate CM. Abstract PURPOSE: A prospective human clinical study was conducted to determine the clinical and histologic bone formation ability of 2 graft materials, a beta-tricalcium phosphate (Cerasorb; Curasan, Kleinostheim, Germany) and autogenous chin bone, in maxillary sinus floor elevation surgery. MATERIALS AND METHODS: Ten healthy patients underwent a bilateral (n = 6) or unilateral (n = 4) maxillary sinus floor elevation procedure under local anesthesia. In each case, residual posterior maxillary bone height was between 4 and 8 mm. In cases of bilateral sinus floor elevation, the original bone was augmented with a split-mouth design with 100% beta-tricalcium phosphate on the test side and 100% chin bone on the contralateral control side. The unilateral cases were augmented with 100% beta-tricalcium phosphate. After a healing period of 6 months, ITI full body screw-type implants (Straumann, Waldenburg, Switzerland) were placed. At the time of implant surgery, biopsy samples were removed with a 3.5-mm trephine drill. RESULTS: Sixteen sinus floor elevations were performed. Forty-one implants were placed, 26 on the test side and 15 on the control side. The clinical characteristics at the time of implantation differed, especially regarding clinical appearance and drilling resistance. The increase in height was examined radiographically prior to implantation and was found to be sufficient in all cases. After a mean of nearly 1 year of follow-up, no implant losses or failures had occurred. DISCUSSION: The promising clinical results of the present study and the lack of implant failures are probably mainly the result of requiring an original bone height of at least 4 mm at the implant location. CONCLUSION: Although autogenous bone grafting is still the gold standard, according to the clinical results, the preimplantation sinus floor elevation procedure used, which involved a limited volume of beta-tricalcium phosphate, appeared to be a clinically reliable procedure in this patient population. Key message: The use of β-TCP in sinus floor elevations appeared to be a clinically relevant alternative to autogenous bone prior to implant placement.

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Localisation of osteogenic and osteoclastic cells in porous beta-tricalcium phosphate particles used for human maxillary sinus floor elevation. Biomaterials. 2005 Apr;26(12):1445-51. Zerbo IR1, Bronckers AL, de Lange G, Burger EH. Abstract We and others have shown earlier that porous beta-tricalcium phosphate (TCP) (Cerasorb) can be used in patients to augment the maxillary sinus floor prior to placement of oral dental implants. To better understand the transformation of TCP particles into bone tissue, we analyse here the appearance of cells with osteogenic or osteoclastic potential in relation to these particles. In biopsies taken at 6 months after sinus floor augmentation we observed bone growth into the TCP particles but also replacement by soft connective tissue. To identify possible osteoprogenitor cells in this tissue, histological sections were immunostained with an antibody to Runx2/Cbfa1, an essential and early transcription factor for osteoblast differentiation. The osteogenic potential of cells was further confirmed by immunostaining for bone sialoprotein (BSP) and osteopontin (OPN). Other sections were stained for Tartrate Resistant Acid Phosphatase (TRAP) activity to identify cells with osteoclastic capacity. Runx2/Cbfa1 positive connective tissue cells were found in abundance throughout and around the TCP particles, even at a distance of several millimetres from the maxillary bone surface. About 95% of the cells found within TCP particles stained positive for Runx2/Cbfa1. Fewer cells stained positive for BSP and OPN, suggesting more mature osteoblastic properties. Mono- and binucleate TRAP-positive cells, but no multinucleate TRAP-positive osteoclasts, were found in the soft tissue infiltrating the TCP and at the surface of the TCP particles. Both the Runx2/Cbfa1 positive and the TRAP-positive cells decreased apically with increasing vertical distance from the maxillary bone surface. This data suggests that the TCP particles attract osteoprogenitor cells that migrate into the interconnecting micropores of the bone substitute material by 6 months. The lack of large multinucleate TRAP positive cells suggests that resorption of the TCP material by osteoclasts plays only a minor role in its replacement by bone. Chemical dissolution, possibly favoured by a high cell metabolism in the particles, seems the predominant cause of TCP degradation. The abundance of Runx2/Cbfa1 positive cells would indicate that with a greater time of healing there will be further bone deposition into these particles. Key message: The migration and differentiation of osteprogenitor in micropores of β-TCP cells were confirmed in this study resulting in bone growth at 6 months. The degradation of β-TCP is favored by chemical dissolution of particles. The effect of covering materials with an open wound in alveolar ridge augmentation using beta-tricalcium phosphate: an experimental study in the dog. Int J Oral Maxillofac Implants. 2012 Nov-Dec;27(6):1413-21. Inomata K1, Marukawa E, Takahashi Y, Omura K. Abstract PURPOSE: This study aimed to examine the effectiveness of a grafting technique using beta-tricalcium phosphate (Β-TCP) covered with different materials in alveolar bone defects with dehiscences. MATERIALS AND METHODS:

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In five beagle dogs, all premolars in the mandible were extracted bilaterally. After a 12-week healing period, two bone defects (length, 5 mm; width, 5 mm; depth, 7 mm) were created on each side of the mandible, and the buccal bone plate was resected. The four bone defects were randomly assigned to one of the following treatments: group 1, Β-TCP alone (TCP group); group 2, Β-TCP graft covered with collagen sponge (TCP+collagen group); group 3, Β-TCP graft covered with free buccal mucosa (TCP+mucosa group); group 4, no treatment (control group). The microarchitecture of the regenerated bone was observed using microcomputed tomography, and the area of newly formed bone was measured. Specimens from each defect were selected and subjected to histologic and histomorphometric analysis; areas of newly formed bone and the ridge width were measured in the specimens. RESULTS: Significant differences were found between the control group and all test groups. The median horizontal width of the ridge 2 mm from the top of the alveolar crest in the TCP+mucosa group was significantly greater than that of the TCP group. There was no significant difference between the TCP+mucosa and TCP+collagen groups in any measurement. CONCLUSIONS: Application of Β-TCP grafts to alveolar bone defects with dehiscence and covering of the open wound with free buccal mucosa or collagen sponge may be useful for ridge augmentation. Compared to no treatment or leaving the wound uncovered, these approaches resulted in more new bone formation and provided adequate horizontal mandibular width. Key message: The use of β-TCP graft covered either with collagen sponge or with free buccal mucosa in alveolar defects with dehiscence increased horizontal width of the ridge and induced new bone formation, it can be applied for ridge augmentation.

IMMEDIATE IMPLANTS – 2 ABSTRACTS

Effect of a multiporous beta-tricalcium phosphate on bone density around dental implants inserted into fresh extraction sockets. J Oral Implantol. 2013 Jun;39(3):339-44. doi: 10.1563/AAID-JOI-D-11-00079. Epub 2011 Sep 26. Daif ET. Abstract The aim of this study was to assess, via multi-slice helical computerized tomography (CT), the influence of the pure-phase multiporous beta-tricalcium phosphate (beta-TCP) on bone density around dental implants inserted into fresh extraction sockets. Twenty-eight patients (18 women and 10 men), indicated for extraction of their lower premolars and insertion of immediate dental implants, were included in this study. They were randomly divided into two equal groups (14 patients each). Group A received immediate dental implants without any filling material around the implants, while in group B, a pure-phase multiporous beta-TCP was gently packed into the bone gaps around the implants. Three and 6 months after loading the implants, a CT, sagittal and coronal, was made to measure the bone density around the implants. The results of the current study have shown that the mean values of the bone density measurements around the implants in group A were 1150 ± 205 (range, 645-1460) at

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3 months and 1245 ± 165 (range, 884-1650) at 6 months after loading the implants. In group B, the mean values of the bone density measurements around the implants were 1280 ± 320 (range, 876-1790) and 1490 ± 358 (range, 1061-1965) at 3 and 6 months after loading the implants, respectively. The statistical analysis of the collected data showed a significant increase in the bone density measurements from 3 to 6 months only in group B (P < .05). Also, the difference between group A and B in the bone density measurements around the implants was statistically significant (P < .05) at only 6 months after loading. On the basis of the results presented in this study, it may be possible to mention that the pure-phase multiporous beta-TCP may enhance the bone density when inserted into the bone gaps around immediate dental implants. Key message: The use of β-TCP in bone gaps around immediate implants resulted in an increase of bone density between 3 and 6 months after placement. Long-term results of implants immediately placed into extraction sockets grafted with β-tricalcium phosphate: a retrospective study J Oral Maxillofac Surg. 2013 Feb;71(2):e63-8. doi: 10.1016/j.joms.2012.09.022. Harel N1, Moses O, Palti A, Ormianer Z. Abstract PURPOSE: The aim of this 10 year retrospective study was to evaluate the crestal bone loss around immediate implant placed in tricalcium phosphate (TCP) grafted extraction sockets MATERIALS AND METHODS: Data were collected from files of 58 patients (33 females, 25 males, average age 54.78 years) undergoing immediate implant placement into fresh extraction socket with or without the use of TCP (Cerasorb, Curasan AG, Kleinostheim, Germany) grafting. After implant placement, horizontal gaps larger than 1.5 mm between the implant surface and the bony plate were grafted with TCP without the use of a membrane, while smaller gaps were not grafted. Two hundred fifty-four implants were inserted: 79 were placed immediately with the use of β-TCP as grafting material (group A), 175 were placed in healed extraction sites, with 61 implants placed with the use of β-TCP graft material (group B), and 114 implants were placed without any grafting material (group C). Bone loss recordings were performed using periapical radiography. Measurements were performed from the neck of the implant to level of the surrounding bone in the vertical dimension. RESULTS: No implant was lost during the follow-up period. Statistical analysis showed no correlation between implant placement timing (delayed or immediate), the use of bone graft, and extent of bone loss. CONCLUSION: The use of TCP (Cerasorb) as a grafting material during immediate implant placement allowed no bone loss in 72.1% of the implants, which was very similar to the nongrafted cases for which implants were placed in favorable conditions. Key message: The use of β-TCP in immediate or delayed implant procedures in case of large gaps (>1.5mm) without the use of a membrane resulted in no bone loss in 72% of the implants.

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OTHER APPLICATIONS IN DENTAL – 8 ABSTRACTS Comparison of hydroxyapatite and beta tricalcium phosphate as bone substitutes after excision of bone tumors. Ogose A1, Hotta T, Kawashima H, Kondo N, Gu W, Kamura T, Endo N. J Biomed Mater Res B Appl Biomater. 2005 Jan 15;72(1):94-101. Abstract Long-term results are reported in 23 patients and short-term results in 30 patients presenting with bone tumors treated by curettage or resection followed by implantation of hydroxyapatite (HA) or highly purified beta-tricalcium phosphate (beta-TCP), respectively. Mean follow-up was 97 and 26 months in cases involving HA implantation and beta-TCP implantation, respectively. Radiographs revealed HA incorporation into host bone in all but two cases; moreover, no obvious evidence of HA biodegradation was observed. A single patient exhibited late deformity following implantation of HA. All grafted beta-TCP was, at least partially, absorbed and replaced by newly formed bone. The mean period required for the disappearance of radiolucent zones between the ceramics and host bone was 17 weeks in HA and 9.7 weeks in beta-TCP. Highly purified beta-TCP appears to be advantageous relative to HA for surgical intervention in bone tumors consequent to the nature of remodeling and superior osteoconductivity. Copyright 2004 Wiley Periodicals, Inc. Key message: β-TCP showed superior osteoconductivity than hydroxyapatite when used in defects following treatments of bone tumors.

Repair of bony defect with combination biomaterials. Velich N1, Németh Z, Hrabák K, Suba Z, Szabó G. J Craniofac Surg. 2004 Jan;15(1):11-5. Abstract BACKGROUND: Numerous possibilities are available for the reconstruction of facial bone defects. The materials used to fill such defects must satisfy various requirements. One of the most important is that they must undergo transformation into autologous bone tissue in the process of remodeling. AIM: A report is given of the long-term results of augmentations of large bone defects performed with different bone-substitute materials in two patients. PATIENTS AND METHODS: In one case, augmentation was carried out with beta-tricalcium phosphate after the removal of a fibromyxoma. In the second case, three large cystic lesions in the mandible of a patient with Gorlin-Goltz syndrome were filled with beta-tricalcium phosphate, with a mixture of beta-tricalcium phosphate and platelet concentrate, or with hydroxyapatite of algal origin. The process of ossification was checked at 6-month intervals by means of clinical, radiologic (orthopantomograms and two-dimensional and three-dimensional computer tomograms), and histologic methods. RESULTS:

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At 1 year after the intervention, the site of the augmentation was in all cases occupied by hard tissue of good quality. With the given imaging procedures, it was difficult to distinguish between the original bone and the region filled with bone-substitute material. The three-dimensional computer tomogram images indicated that the contours and quality of the new bone corresponded with the physiologic and anatomical conditions. The histologic examinations show the remodeling of the bone-substitute materials. DISCUSSION: The bone-substitute materials applied in these cases fully satisfied the demands of transformation into bone (remodeling). The speed of remodeling seemed to be the fastest when the mixture of beta-tricalcium phosphate and platelet concentrate was used. Key message: β-TCP allowed the formation of new hard mineralized tissue. A faster remodeling was observed when combining β-TCP with platelet concentrate. Le Fort I osteotomy in atrophied maxilla and bone regeneration with pure-phase beta-tricalcium phosphate and PRP. Foitzik C1, Staus H. Implant Dent. 2003;12(2):132-9. Abstract Le Fort I osteotomy is a versatile procedure in oral and maxillofacial surgery for the correction of dysgnathias as well as for an easy approach to the surgical site in neurosurgery; however, it is rarely performed for a vertical advancement of the maxilla. This paper presents the successful use of the synthetic pure-phase beta-tricalcium phosphate (beta-TCP) Cerasorb (Curasan, Kleinostheim, Germany), together with autogenous bone at a ratio of 4:1, in combination with patients' own platelet-rich plasma for a vertical augmentation of completely atrophied maxillae, resulting in an advancement of 16 and 14 mm, respectively. After a period of 8 months the beta-TCP was completely resorbed and the x-ray control showed no residual granules in the defect sites. Pure-phase beta-TCP proved to be a bone-regeneration material, providing the patient with vital bone at the defect site in a reasonable time, making a second surgical procedure for bone harvesting (e.g., at the iliac crest) unnecessary. The relapse of approximately one third in the second case did not affect the success of treatment and was attributed to the combination of platelet-rich plasma with a resorbable polylactic membrane. Thus, in the combination of pure-phase beta-TCP and platelet-rich plasma, the use of nonresorbable membranes and suture materials is recommended. These results encourage the qualified surgeon to use the pure-phase beta-TCP for bone regeneration even when performing augmentations of this dimension. Key message: The use of β-TCP together with PRP in Le Fort I osteotomy procedures showed bone regeneration. Histologic effect of pure-phase beta-tricalcium phosphate on bone regeneration in human artificial jawbone defects. Trisi P1, Rao W, Rebaudi A, Fiore P. Int J Periodontics Restorative Dent. 2003 Feb;23(1):69-77. Abstract

OTHER APPLICATIONS IN DENTAL – 8 ABSTRACTS Comparison of hydroxyapatite and beta tricalcium phosphate as bone substitutes after excision of bone tumors. Ogose A1, Hotta T, Kawashima H, Kondo N, Gu W, Kamura T, Endo N. J Biomed Mater Res B Appl Biomater. 2005 Jan 15;72(1):94-101. Abstract Long-term results are reported in 23 patients and short-term results in 30 patients presenting with bone tumors treated by curettage or resection followed by implantation of hydroxyapatite (HA) or highly purified beta-tricalcium phosphate (beta-TCP), respectively. Mean follow-up was 97 and 26 months in cases involving HA implantation and beta-TCP implantation, respectively. Radiographs revealed HA incorporation into host bone in all but two cases; moreover, no obvious evidence of HA biodegradation was observed. A single patient exhibited late deformity following implantation of HA. All grafted beta-TCP was, at least partially, absorbed and replaced by newly formed bone. The mean period required for the disappearance of radiolucent zones between the ceramics and host bone was 17 weeks in HA and 9.7 weeks in beta-TCP. Highly purified beta-TCP appears to be advantageous relative to HA for surgical intervention in bone tumors consequent to the nature of remodeling and superior osteoconductivity. Copyright 2004 Wiley Periodicals, Inc. Key message: β-TCP showed superior osteoconductivity than hydroxyapatite when used in defects following treatments of bone tumors.

Repair of bony defect with combination biomaterials. Velich N1, Németh Z, Hrabák K, Suba Z, Szabó G. J Craniofac Surg. 2004 Jan;15(1):11-5. Abstract BACKGROUND: Numerous possibilities are available for the reconstruction of facial bone defects. The materials used to fill such defects must satisfy various requirements. One of the most important is that they must undergo transformation into autologous bone tissue in the process of remodeling. AIM: A report is given of the long-term results of augmentations of large bone defects performed with different bone-substitute materials in two patients. PATIENTS AND METHODS: In one case, augmentation was carried out with beta-tricalcium phosphate after the removal of a fibromyxoma. In the second case, three large cystic lesions in the mandible of a patient with Gorlin-Goltz syndrome were filled with beta-tricalcium phosphate, with a mixture of beta-tricalcium phosphate and platelet concentrate, or with hydroxyapatite of algal origin. The process of ossification was checked at 6-month intervals by means of clinical, radiologic (orthopantomograms and two-dimensional and three-dimensional computer tomograms), and histologic methods. RESULTS:

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The effect of the pure-phase beta-tricalcium phosphate (beta-TCP) Cerasorb on bone regeneration was evaluated in hollow titanium cylinders implanted in the posterior jaws of five volunteers. Beta-TCP particles were inserted inside the cylinders and harvested 6 months after placement. The density of the newly formed bone inside the bone-growing chambers measured 27.84% +/- 24.67% in test and 17.90% +/- 4.28% in control subjects, without a statistically significant difference. Analysis of the histologic specimens revealed that the density of the regenerated bone was related to the density of the surrounding bone. The present study demonstrates the spontaneous healing of infrabony artificial defects, 2.5 mm diameter, in the jaw. The pure beta-TCP was resorbed simultaneously with new bone formation, without interference with the bone matrix formation. Key message: After 6 months, β-TCP resorbed while new bone was forming, without interference with the bone matrix, when used in artificial jawbone defects. A concept for the treatment of various dental bone defects. Palti A1, Hoch T. Implant Dent. 2002;11(1):73-8. Abstract Untreated dental bone defects usually lead to resorption of alveolar bone. Filling these defects with bone substitute material prevents resorption of bone, preserves the alveolar ridge, and provides sufficient bone for immediate or subsequent implant placement. A variety of bone substitutes is available. They differ in origin, consistency, particle size, porosity, and resorption characteristics. We have treated almost 1000 bony defect sites in 267 patients with the bone regeneration material Cerasorb. Being resorbed simultaneously with the formation of new bone, it is completely replaced by the patient's own vital bone within 6 to 12 months. The representative cases described in this paper demonstrate the successful use of the pure-phase beta-tricalcium phosphate ceramic in the treatment of all dental bone defects. Key message: Pure-phase beta-tricalcium phosphate ceramic is completely resorbed and replaced by the patient’s own bone in 6 to 12 months, with successful results when used in various bone defects. Tricalcium phosphate ceramic-a resorbable bone implant: review and current status. Metsger DS, Driskell TD, Paulsrud JR. J Am Dent Assoc. 1982 Dec;105(6):1035-8. Abstract Fourteen animal studies involving the implantation of beta-tricalcium phosphate ceramic (TPC) in rats, dogs, and primates have shown the material to be effective in repairing many types of bony defects. Histological examinations confirm that the implant is resorbed and concomitantly replaced by normal bone when firmly fixed to freshly cut and bleeding bone. Tissue compatibility has been shown to be superior to other synthetic materials. TPC has been used in human clinical studies to repair marginal and periapical periodontal defects, as well as apexification and miscellaneous alveolar bony defects. When used to repair marginal periodontal defects, degrees of repair equaled or exceeded those obtained using autogenous bone. Complete bone fill, as evidenced by radiography, was observed in the repair of two-

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and three-walled periapical defects. TPC afforded a better barrier than calcium hydroxide in the obturation of open apexes and provided equivalent repair. No adverse reactions attributable to TPC have been reported. Key message: It has been shown that β-TCP resorbs while being replaced by normal bone, with a superior tissue compatibility and provided a similar or higher degree of repair than autogenous bone when used in marginal periodontal defects. Transcriptome analysis of β-TCP implanted in dog mandible. Bone. 2011 Apr 1;48(4):864-77. doi: 10.1016/j.bone.2010.11.019. Epub 2010 Dec 4. Zhao J1, Watanabe T, Bhawal UK, Kubota E, Abiko Y. Abstract Beta-tricalcium phosphate (β-TCP) is widely used in clinical orthopedic surgery due to its high biodegradability, osteoconductivity, easy manipulation and lack of histotoxicity. However, little is known about the molecular mechanisms responsible for the beneficial effects of β-TCP in bone formation. In this study, β-TCP was implanted in dog mandibles, after which the gene expression profiles and signaling pathways were monitored using microarray and Ingenuity Pathways Analysis (IPA). Following the extraction of premolars and subsequent bone healing, β-TCP was implanted into the artificial osseous defect. Histological evaluation (H-E staining) was carried out 4, 7 and 14 days after implantation. In addition, total RNA was isolated from bone tissues and gene expression profiles were examined using microarray analysis coupled with Ingenuity Pathways Analysis (IPA). Finally, real-time PCR was used to confirm mRNA levels. It was found that β-TCP implantation led to a two-fold change in 3409 genes on day 4, 3956 genes on day 7, and 6899 genes on day 14. Among them, the expression of collagen type I α1 (COL1A1), alkaline phosphatase (ALP) and transforming growth factor (TGF)-β2 was increased on day 4, the expression of receptor activator of NF-kappaB ligand (RANKL) and interferon-γ (IFN-γ) was decreased on day 7, and the expression of osteoprotegerin (OPG) was decreased on day 14, affecting the bone morphogenetic protein (BMP), Wnt/β-catenin and nuclear factor-kappaB (NF-κB) signaling pathways in osteoblasts and osteoclasts. Simultaneously, vascular cell adhesion molecule (VCAM)-1 expression was increased on day 4 and stromal cell-derived factor (SDF)-1 expression was increased on days 4 and 14. Taken together, these findings shed light on some of the cellular events associated with bone formation, bioresorption, regeneration and healing of β-TCP following its implantation. The results suggest that β-TCP enhances bone healing processes and stimulates the coordinated actions of osteoblasts and osteoclasts, leading to bone regeneration. Key message: The results suggest that β-TCP enhances bone healing processes and stimulates pro-osteoblastic factors and modulates pro-osteoclastic factors resulting in bone regeneration. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study and morphometric analysis. Artzi Z1, Weinreb M, Givol N, Rohrer MD, Nemcovsky CE, Prasad HS, Tal H. Int J Oral Maxillofac Implants. 2004 May-Jun;19(3):357-68.

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Abstract PURPOSE: An inorganic xenograft (inorganic bovine bone [IBB]) and a porous alloplast (beta-tricalcium phosphate [beta-TCP]) material were compared at different healing periods in experimental bone defects in dogs. MATERIALS AND METHODS: Six round defects, 5 x 4 mm, were made on the lateral bony mandibular angle in 8 dogs at different times. Two defects were randomly filled with IBB, 2 with beta-TCP, and 2 were left to blood clot. A bi-layer collagen membrane covered 1 defect of each type. Four specimens per treatment group were obtained for each treatment group at 3, 6, 12, and 24 months postoperatively. Morphometric analysis of decalcified (Donath technique) histologic slides was conducted using the measured areas of regenerated bone, grafted particles, and remaining concavity. RESULTS: In IBB sites, complete bone healing was evident at 12 and 24 months, but grafted particles dominated the sites. In beta-TCP sites, only particle remnants remained at 12 months. At 24 months, particles had completely resorbed in both membrane-protected (MP) and uncovered (UC) defects. Data were combined for final analysis since there were no statistically significant differences within each graft material group (MP or UC). Mean bone area fraction increased from 3 to 24 months at all sites. In bone area fraction a statistically significant difference was found between 3 and 6 months in the IBB and beta-TCP groups. IBB sites also showed such significance between 6 and 12 months. A statistically significant difference was found between MP ungrafted sites (42.9%) vs IBB (24.7%) and vs the control (24.8%) at 3 months. At 6 months, beta-TCP bone area fraction (68.8%) was significantly greater than IBB (47.9%) and control (37.5%) sites. At 12 months, beta-TCP bone area fraction (79.0%) was significantly greater than the control (42.5%). At 24 months, beta-TCP bone area fraction (86.5%) was significantly greater than IBB (55.6%) sites. Mean particle area fraction of beta-TCP sites decreased gradually until complete resorption at 24 months. IBB sites showed a significant decrease only between 3 (38.7%) and 6 (29.4%) months. DISCUSSION AND CONCLUSION: Complete bone healing was established in all grafted defects. IBB and beta-TCP are both excellent biocompatible materials. However, at 24 months beta-TCP particles were completely resorbed, whereas IBB particles still occupied a remarkable area fraction without significant resorption beyond 6 months. (More than 50 references.) Key message: β-TCP allowed complete healing with only particle remnants left at 12 months and complete resorption at 24 months. On the contrary, in sites treated with inorganic bovine bone particles dominated.

NON DENTAL APPLICATIONS – 6 ABSTRACTS

Tissue-engineered bone using mesenchymal stem cells and a biodegradable scaffold. Boo JS1, Yamada Y, Okazaki Y, Hibino Y, Okada K, Hata K, Yoshikawa T, Sugiura Y, Ueda M.

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J Craniofac Surg. 2002 Mar;13(2):231-9; discussion 240-3. Abstract Bone marrow has been shown to contain a population of rare cells capable of differentiating to the cells that form various tissues. These cells, referred to as mesenchymal stem cells (MSCs), are capable of forming bone when implanted ectopically in an appropriate scaffold. The aim of this study was to investigate the potential of a new beta-tricalcium phosphate (beta-TCP) as a scaffold and to compare the osteogenic potential between beta-TCP and hydroxyapatite (HA). The beta-TCP and HA loaded with MSCs were implanted in subcutaneous sites and harvested at 1, 2, 4, and 8 weeks after implantation for biochemical and histological analysis. Biochemically, in both beta-TCP and HA composites, the alkaline phosphatase activity in the composites could be detected and was maintained at a high level for 8 weeks. In the histological analysis, active bone formation could be found in both the beta-TCP and HA composites. These findings suggest that beta-TCP could play a role as a scaffold as well as HA. The fabricated synthetic bone using biodegradable beta-TCP as a scaffold in vivo is useful for reconstructing bone, because the scaffold material is absorbed several months after implantation. Key message: β-TCP loaded with mesenchymal stem cells showed active bone formation suggesting its role as a resorbable scaffold. Beta-tricalcium phosphate as a bone substitute for dorsal spinal fusion in adolescent idiopathic scoliosis: preliminary results of a prospective clinical study. Muschik M1, Ludwig R, Halbhübner S, Bursche K, Stoll T. Eur Spine J. 2001 Oct;10 Suppl 2:S178-84. Abstract The aim of this study is to evaluate the ability of beta-tricalcium phosphate (TCP) in granular form to achieve dorsal spondylodesis in adolescent idiopathic scoliosis (AIS). Twenty-eight patients underwent surgical correction and were followed up for 13+/-8 (range 6-33) months. Posterolateral grafting was performed, using either autograft bone mixed with allograft bone (n=19; "bone group") or autograft bone mixed with 25 g TCP (n=9; "TCP group"). Patients were followed by clinical examination, X-rays and computed tomographic (CT) scans to measure bone mineral density. Fusion involved 12+/-1 (range 10-14) vertebrae. The segments were fused after 6+/-1 months in both groups according to the radiographs. No pseudarthrosis was observed. Bone mineral density was 430+/-111 (range 273-629) mg/cm3 in the TCP group versus 337+/-134 (range 130-669) mg/cm3 in the bone group. Resorption of TCP was complete on the radiographs after 8+/-2 (range 6-10) months. Based upon the results of this small preliminary study, the use of TCP appears to be a valuable alternative to allografts for application in the spine, even when large amounts of bone are needed. Key message: β-TCP may be used in combination with autogenous bone for application in large bone defects located in the spine and be an alternative to allograft bone. Filling of bone defects with tricalcium phosphate beta in traumatology [Article in French] Ann Chir. 2000 Dec;125(10):972-81. Galois L1, Mainard D, Cohen P, Pfeffer F, Traversari R, Delagoutte JP.

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Author information Abstract AIM OF STUDY: Synthetic bone substitutes like calcium phosphate ceramics have been used in orthopaedic surgery for several years. The aim of this study was to assess the results of the use of tricalcium phosphate beta for filling bone defects in trauma cases. PATIENTS AND METHOD: beta tricalcium phosphate was used in 24 trauma cases. The GESTO classification (Association pour l'étude des Greffes et Substituts Tissulaires en Orthopédie) and a qualitative scale were used to estimate the integration. RESULTS: With a mean follow-up of 20 months, integration was excellent in 41.2%, good in 29.2% and moderate in 17.4%. No fibrous encapsulation was observed around the implants in any case. Sepsis occurred in 3 cases with open fractures. CONCLUSION: beta-Tricalcium phosphate seems in our experience to be an excellent bone substitute for filling bone defects in trauma cases. Key message: β-TCP, already used for filling bone defects in orthopedic surgery may also be used in trauma cases. Bone ingrowth into two porous ceramics with different pore sizes : An experimental study Acta Orthopædica Belgica, Vol. 70 - 6 – 2004 Laurent GALOIS, Didier MAINARD Many properties of porous calcium phosphate ceramics have been described, but how pore size influences bony integration of various porous ceramics remains unclear. This study was performed to quantify the bony ingrowth and biodegradability of two porous calcium phosphate ceramics with four different pore size ranges (45-80 μm, 80-140 μm, 140-200 μm, and 200-250 μm). Hydroxyapatite (HA) and b-tricalcium phosphate (TCP) cylinders were implanted into the femoral condyles of rabbits and were left in situ for up to 12 months. The percentage of bone ingrowth and the depth of ingrowth within the pores were determined. Biodegradability of the implants was also evaluated. Bone ingrowth occurred at a higher rate into the TCP than into the HA ceramics with the same pore size ranges. The amount of newly formed bone was statistically smaller (p < 0.05) into ceramics with 45-80 μm pore size than with larger pore size, whatever the implantation time for HA and until four months for TCP. No statistical difference was noted between the three highest pore size ranges. No implant degradation was noted up to four months. Our results suggest that a pore size above 80 μm improves bony ingrowth in both HA and TCP ceramics. Bone formation was higher in the TCP than in the HA implants. Key message: At 12 months, β-TCP used in femoral condyles of rabbits resulted in more bone formation when size of pores superior to 80 µm.

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Bone formation and resorption of highly purified b-tricalcium phosphate in the rat femoral condyle Biomaterials 26 (2005) 5600–5608 Naoki Kondo, Akira Ogosea, Kunihiko Tokunaga, Tomoyuki Ito, Katsumitsu Arai, Naoko Kudo, Hikaru Inoue, Hiroyuki Irie, Naoto Endo Abstract The aim of this study was to examine the chronological histology associated with highly purified b-tricalcium phosphate (β-TCP) implanted in the rat femoral condyle. Specimens were harvested on days 4, 7, 14, 28 and 56 after implantation, and were analyzed by tartrate-resistant acid phosphatase (TRAP) staining, immunohistochemistry of the ED1 protein as a marker of the phagocyte system, and in situ hybridization with digoxigenin-labeled a1 chain of type I procollagen (COL1A1), osteopontin and osteocalcin. β -TCP was resorbed in a chronological manner. Although new bone was not observed on day 4, fibroblast-like cells around β -TCP were positive for COL1A1 and osteopontin mRNA. New bone formation presented after day 7. In the double-staining for OPN and ED1 on day 7, most cells around β -TCP were positive for either osteopontin mRNA or ED1 protein. However, there were some doubly positive multinucleated cells, suggesting that they belonged to the mononuclear phagocyte system. After day 28, the implanted region was replaced with bone marrow. Multinucleated TRAP-positive and ED1-positive cells which adhered to β -TCP at all stages seemed to be osteoclasts and they continuously resorbed β -TCP. β -TCP has a good biocompatibility since both bioresorption and bone formation started at an early stage after implantation. Key message: The biocompatibility of β-TCP is demonstrated in this study. When β-TCP is used in rat femoral condyle, new bone formation (day 7) and bioresorption (day 28) were observed at an early stage. Osteoclasts would be involved in the continuous resorption of β-TCP. Degradation characteristics of alpha and beta tri-calcium-phosphate (TCP) in minipigs. Wiltfang J1, Merten HA, Schlegel KA, Schultze-Mosgau S, Kloss FR, Rupprecht S, Kessler P. J Biomed Mater Res. 2002;63(2):115-21. Abstract In seven Goettingen minipigs 3.5--4.7-ml cancellous bone defects were created in the area of the tibial head on both sides. The defects were filled with alpha-TCP or beta-TCP (tricalciumphosphate). ITI implants (Straumann, Freiburg, Germany) of 3.2 x 12-mm length were inserted into the underlying ceramic substitutes. Two additional pigs were used as control. Within the periods of observation (4, 16, 20, 28, 46, 68, and 86 weeks) fluorescent dyes were applied. Nondecalcified thin-sliced sections were examined by means of light and fluorescence microscopy. In addition microangiography and microradiography were performed. Bony regeneration occurred basally and on the sides of the defect according the angiogenetic reossification pattern. Resorption was due to a hydrolytic and cellular degradation process. After 46 weeks histomorphological evaluation showed an incomplete osseointegration of the simultaneously implanted dental implants. The bone contact surface ratio was lower than 25%. After 86 weeks 95--97% of both alpha- and beta-TCP were resorbed. Ceramic residuals stayed within the newly formed trabeculae thus resisting further

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degradation until remodeling occurred. Both alpha- and beta-TCP show a comparable degradation process. At the 86-week postoperative point only small residuals of the ceramic can be found. These residuals stay within the newly formed trabeculae, which show a functional orientation. In comparison control defects showed only sparse reossification. The beta-TCP material shows an accelerated degradation mode and has an optimal reactivity with the surrounding tissues. According to the results of this animal experiment both materials can be classified as bone-rebuilding materials. Key message: β-TCP used in cancellous bone defects showed an advanced (97%) degradation at 86 weeks and optimal reactivity with surrounding tissues.

IN VITRO STUDIES – 2 ABSTRACTS

Effects of tricalcium phosphate bone graft materials on primary cultures of osteoblast cells in vitro. Aybar B1, Bilir A, Akçakaya H, Ceyhan T. Clin Oral Implants Res. 2004 Feb;15(1):119-25. Abstract The aim of this study was to evaluate beta-tricalcium phosphate (beta-TCP Cerasorb Curasan-Germany) graft materials on specific parameters of rat osteoblast activity in vitro. Primary culture osteoblastic cells were isolated from neonatal rat calvaria by sequential collagenase digestion. To analyze the effect of biomaterials on cell proliferation, cell numbers and viability of the cells were cultured on the graft material for 24, 48 or 96 h. Osteoblast cells cultured in DMEF-12 media supplemented with 10% fetal calf serum were used as the control group. [3H]thymidine was added during the last 2 h of the incubation. The cell numbers of each well were counted. Cell viability was estimated by counting the number of cells, which excluded trypan blue solution. Scanning electron microscopy was used to observe for visualizing the interactions between osteoblastic cells and TCP graft material. The proportion of cells undergoing DNA synthesis, estimated by thymidine uptake, was significantly (P<0.05) greater on the control group after the 24- and 48-h incubations. Regarding the cell numbers the difference was not statistically significant for the three time points. The number of viable cells recovered was similar for the two groups. No morphological differences were observed in cell morphology on TCP graft material and the control group. The results demonstrate that TCP graft material has no adverse effect on cell count, viability and morphology, and this material provides a matrix that favors limited cell proliferation. Key message: β-TCP showed neither cytotoxicity nor cell morphology effect in osteoblastic cells. Moreover, β-TCP favors osteoblastic proliferation in primary culture. The experimental study on mixed culture of osteoblasts and tricalcium phosphate ceramics in vitro. Zeng H1, Du J, Zheng Q, Liu Y, Guo X. J Tongji Med Univ. 1999;19(2):131-4.

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Abstract To study the effects of tricalcium phosphate (TCP) ceramics on osteoblasts, the rat osteoblasts were cultured with the TCP ceramics in vitro. Scanning electron microscopy and the colorimetric methyl-thiazol-tetrazolium assay showed that the osteoblasts could adhere well to the surface of the ceramics and the culture dish, and the proliferation of the cells was not inhibited. The results demonstrated that TCP ceramics possessed an excellent cytocompatibility with the osteoblasts, and had some promoting effects on proliferation of osteoblasts. Key message: β-TCP has shown high cytocompatibility and promoting effect on proliferation with osteoblasts.

This literature list is an overview of the most relevant references about studies and investigations on beta-tricalcium phosphate. There is no claim for completeness.

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2. FULL ARTICLES OF SCIENTIFIC

STUDIES & CLINICAL CASES ON R.T.R.

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EXTRACTION SOCKET PRESERVATION – 3 ARTICLES

Beta-tricalcium phosphate / type I collagen cones with or without a barrier membrane in human extraction socket healing: clinical, histomorphometric and immunohistochemical evalutation B. Brkovic, H. Prasad, M. Rohrer, G. Konandreas,G. Agrogiannis, D. Antunovic, G. Sandor Clin Oral Invest. 2012 Apr;16(2):581-90. doi: 10.1007/s00784-011-0531-1. Epub 2011 Mar 3.

Simple preservation of a maxillary extraction socket using beta-tricalcium phosphate with type I collagen: Preliminary clinical andhistomorphometric observations B. Brkovic, H. Prasad, G. Konandreas, R. Milan, D. Antunovic, M. Rohrer J. Can Dent Assoc. 2008 Jul-Aug;74(6):523-8.

Bone regeneration with ß-tricalcium phosphate (R.T.R.) in post-extraction sockets Dr. O.H. Arribasplata Loconi Septodont Case Studies Collection n°7, March 2014, p12-20

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EXTRACTION SOCKET PRESERVATION – 3 ARTICLES

Beta-tricalcium phosphate / type I collagen cones with or without a barrier membrane in human extraction socket healing: clinical, histomorphometric and immunohistochemical evalutation B. Brkovic, H. Prasad, M. Rohrer, G. Konandreas,G. Agrogiannis, D. Antunovic, G. Sandor Clin Oral Invest. 2012 Apr;16(2):581-90. doi: 10.1007/s00784-011-0531-1. Epub 2011 Mar 3.

Simple preservation of a maxillary extraction socket using beta-tricalcium phosphate with type I collagen: Preliminary clinical andhistomorphometric observations B. Brkovic, H. Prasad, G. Konandreas, R. Milan, D. Antunovic, M. Rohrer J. Can Dent Assoc. 2008 Jul-Aug;74(6):523-8.

Bone regeneration with ß-tricalcium phosphate (R.T.R.) in post-extraction sockets Dr. O.H. Arribasplata Loconi Septodont Case Studies Collection n°7, March 2014, p12-20

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ClinicalP r a c t i c e

Simple Preservation of a Maxillary Extraction Socket Using Beta-tricalcium Phosphate with Type I Collagen: Preliminary Clinical and Histomorphometric ObservationsBozidar M.B. Brkovic, DDS, MSc, PhD; Hari S. Prasad, BS, MDT; George Konandreas, DDS; Radulovic Milan, DDS, MSc; Dragana Antunovic, DDS; George K.B. Sándor, MD, DDS, PhD, FRCD(C), FRCSC, FACS; Michael D. Rohrer, DDS, MS

ABSTRACT

Alveolar atrophy following tooth extraction remains a challenge for future dental implant placement. Immediate implant placement and postextraction alveolar preservation are 2 methods that are used to prevent significant postextraction bone loss. In this article, we report the management of a maxillary tooth extraction socket using an alveolar pres-ervation technique involving placement of a cone of beta-tricalcium phosphate (ß-TCP) combined with type I collagen without the use of barrier membranes or flap surgery. Clinical examination revealed solid new bone formation 9 months after the procedure. At the time of implant placement, histomorphometric analysis of the biopsied bone showed that it contained 62.6% mineralized bone, 21.1% bone marrow and 16.3% residual ß-TCP graft. The healed bone was able to support subsequent dental implant placement and loading.

After tooth extraction, the residual al-veolar ridge generally provides lim-ited bone volume because of ongoing,

progressive bone resorption.1 Healing events within postextraction sockets reduce the di-mensions of the socket over time.2 A reduction of about 50% in both horizontal and vertical directions has been observed over 12 months, with two-thirds of the reduction occurring in the first 3 months.3 The rate and pattern of bone resorption may be altered if pathologic and traumatic processes have damaged 1 or

more of the bony walls of the socket. In these circumstances, fibrous tissue will likely occupy part of the socket, preventing normal healing and osseous regeneration.3 These morphologic changes may affect the successful placement and osseointegration of dental implants.

When considering ways to preserve ad-equate bone volume, clinicians frequently ask whether filling bone defects, such as al-veolar postextraction sockets, with resorbable osteoconductive materials is warranted.4–6 Although autogenous bone is still considered

Contact Author

Dr. SándorEmail: [email protected]

For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-74/issue-6/xxx.html

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the gold standard for grafting procedures, limitations, such as donor site morbidity from bone graft harvesting techniques,7 have stimulated the search for suitable syn-thetic grafting materials. Although barrier membranes may be used to guide bone regeneration, wound dehis-cence may lead to early exposure and infection of the membrane followed by reduction in the volume and quality of bone.8,9

Beta-tricalcium phosphate (β-TCP), a synthetic allo-plastic material, has been used for bone regeneration in a variety of surgical procedures with satisfactory clin-ical and histologic results in both animal models10,11 and human trials.12,13 β-TCP may be a suitable bone substitute that will biodegrade and be replaced by newly mineral- izing bone tissue without fibrous tissue proliferation.12 Bony regeneration has been reported in cases where β-TCP was used without a barrier membrane in patients undergoing sinus floor elevation and mandibular cyst re-moval.12 It is also possible to combine β-TCP with platelet-rich plasma, other growth factors or collagen to potentially accelerate the process of bone regeneration.14,15

There have been no reports on the use of β-TCP com-bined with type I collagen for postextraction socket preservation without the use of a barrier membrane or mucoperiosteal flap to cover the implanted material. The purpose of this article is to present clinical, radio-

graphic, histologic and histomorphometric results for a patient treated with β-TCP in combination with type I collagen for alveolar preservation before dental implant placement.

Case ReportA 28-year-old healthy male non-smoker with good

oral hygiene required the extraction of a left maxillary second premolar (tooth 25) before placement of a dental implant for prosthodontic rehabilitation (Fig. 1a). The tooth had to be extracted as it was severely broken down (Fig. 1b). The alveolar preservation protocol was approved by the institution’s ethical review board and written in-formed consent was obtained from the patient after the risks and benefits were explained to him.

After administration of local anesthesia, an intrasul-cular incision was made to raise a distal papilla and marginal gingiva. This exposed the marginal bone to allow visualization and measurement of the alveolar bone level (Fig. 1c). Extraction of the tooth was performed using a straight elevator and forceps without the eleva-tion of flaps. After extraction of the tooth, the socket was thoroughly curetted. β-TCP with type I collagen (RTR Cone, Septodont, Saint-Maur-des-Fossés, France) was placed in the alveolar socket occupying the space from

Figure 1a: Periapical radiograph of deteri-orated left maxillary second premolar before extraction.

Figure 1b: Remnant of the maxillary second premolar structure with extensive coronal destruction.

Figure 1c: Determination of the cre-stal alveolar bone level before socket preservation.

Figure 1d: Placement of ß-TCP combined with type I collagen (RTR Cone) at the extraction site.

Figure 1e: ß-TCP combined with type I collagen implant secured with a single suture without a barrier membrane or mucoperiosteal flap.

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the gold standard for grafting procedures, limitations, such as donor site morbidity from bone graft harvesting techniques,7 have stimulated the search for suitable syn-thetic grafting materials. Although barrier membranes may be used to guide bone regeneration, wound dehis-cence may lead to early exposure and infection of the membrane followed by reduction in the volume and quality of bone.8,9

Beta-tricalcium phosphate (β-TCP), a synthetic allo-plastic material, has been used for bone regeneration in a variety of surgical procedures with satisfactory clin-ical and histologic results in both animal models10,11 and human trials.12,13 β-TCP may be a suitable bone substitute that will biodegrade and be replaced by newly mineral- izing bone tissue without fibrous tissue proliferation.12 Bony regeneration has been reported in cases where β-TCP was used without a barrier membrane in patients undergoing sinus floor elevation and mandibular cyst re-moval.12 It is also possible to combine β-TCP with platelet-rich plasma, other growth factors or collagen to potentially accelerate the process of bone regeneration.14,15

There have been no reports on the use of β-TCP com-bined with type I collagen for postextraction socket preservation without the use of a barrier membrane or mucoperiosteal flap to cover the implanted material. The purpose of this article is to present clinical, radio-

graphic, histologic and histomorphometric results for a patient treated with β-TCP in combination with type I collagen for alveolar preservation before dental implant placement.

Case ReportA 28-year-old healthy male non-smoker with good

oral hygiene required the extraction of a left maxillary second premolar (tooth 25) before placement of a dental implant for prosthodontic rehabilitation (Fig. 1a). The tooth had to be extracted as it was severely broken down (Fig. 1b). The alveolar preservation protocol was approved by the institution’s ethical review board and written in-formed consent was obtained from the patient after the risks and benefits were explained to him.

After administration of local anesthesia, an intrasul-cular incision was made to raise a distal papilla and marginal gingiva. This exposed the marginal bone to allow visualization and measurement of the alveolar bone level (Fig. 1c). Extraction of the tooth was performed using a straight elevator and forceps without the eleva-tion of flaps. After extraction of the tooth, the socket was thoroughly curetted. β-TCP with type I collagen (RTR Cone, Septodont, Saint-Maur-des-Fossés, France) was placed in the alveolar socket occupying the space from

Figure 1a: Periapical radiograph of deteri-orated left maxillary second premolar before extraction.

Figure 1b: Remnant of the maxillary second premolar structure with extensive coronal destruction.

Figure 1c: Determination of the cre-stal alveolar bone level before socket preservation.

Figure 1d: Placement of ß-TCP combined with type I collagen (RTR Cone) at the extraction site.

Figure 1e: ß-TCP combined with type I collagen implant secured with a single suture without a barrier membrane or mucoperiosteal flap.

514 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 •

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the gold standard for grafting procedures, limitations, such as donor site morbidity from bone graft harvesting techniques,7 have stimulated the search for suitable syn-thetic grafting materials. Although barrier membranes may be used to guide bone regeneration, wound dehis-cence may lead to early exposure and infection of the membrane followed by reduction in the volume and quality of bone.8,9

Beta-tricalcium phosphate (β-TCP), a synthetic allo-plastic material, has been used for bone regeneration in a variety of surgical procedures with satisfactory clin-ical and histologic results in both animal models10,11 and human trials.12,13 β-TCP may be a suitable bone substitute that will biodegrade and be replaced by newly mineral- izing bone tissue without fibrous tissue proliferation.12 Bony regeneration has been reported in cases where β-TCP was used without a barrier membrane in patients undergoing sinus floor elevation and mandibular cyst re-moval.12 It is also possible to combine β-TCP with platelet-rich plasma, other growth factors or collagen to potentially accelerate the process of bone regeneration.14,15

There have been no reports on the use of β-TCP com-bined with type I collagen for postextraction socket preservation without the use of a barrier membrane or mucoperiosteal flap to cover the implanted material. The purpose of this article is to present clinical, radio-

graphic, histologic and histomorphometric results for a patient treated with β-TCP in combination with type I collagen for alveolar preservation before dental implant placement.

Case ReportA 28-year-old healthy male non-smoker with good

oral hygiene required the extraction of a left maxillary second premolar (tooth 25) before placement of a dental implant for prosthodontic rehabilitation (Fig. 1a). The tooth had to be extracted as it was severely broken down (Fig. 1b). The alveolar preservation protocol was approved by the institution’s ethical review board and written in-formed consent was obtained from the patient after the risks and benefits were explained to him.

After administration of local anesthesia, an intrasul-cular incision was made to raise a distal papilla and marginal gingiva. This exposed the marginal bone to allow visualization and measurement of the alveolar bone level (Fig. 1c). Extraction of the tooth was performed using a straight elevator and forceps without the eleva-tion of flaps. After extraction of the tooth, the socket was thoroughly curetted. β-TCP with type I collagen (RTR Cone, Septodont, Saint-Maur-des-Fossés, France) was placed in the alveolar socket occupying the space from

Figure 1a: Periapical radiograph of deteri-orated left maxillary second premolar before extraction.

Figure 1b: Remnant of the maxillary second premolar structure with extensive coronal destruction.

Figure 1c: Determination of the cre-stal alveolar bone level before socket preservation.

Figure 1d: Placement of ß-TCP combined with type I collagen (RTR Cone) at the extraction site.

Figure 1e: ß-TCP combined with type I collagen implant secured with a single suture without a barrier membrane or mucoperiosteal flap.

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––– Socket Preservation –––

the crest of the alveolus to the apex of the socket (Fig. 1d). The socket was filled with the alloplastic mate-rial, but not covered with any barrier membrane or mu-coperiosteal flap. The distobuccal and palatal papillae and attached gingiva at the extraction site were stabilized with a single interrupted suture to reduce the opening of the socket and the amount of exposed material (Fig. 1e). The patient was prescribed a course of antibiotic and pain medications with postoperative instructions for 7 days, at which point the suture was removed.

The patient was examined at 3, 5 and 7 days, then at 4 and 9 months postoperatively; radiographs were taken at 1 week, 4 months and 9 months following placement of the alloplastic material (Figs. 2a–2e). After 9 months, a trephine, 2 mm in diameter and 6 mm in length, was used to collect a bone sample from the treated extraction socket during dental implant placement (Figs. 2f to 2h).

The bone biopsy specimen was prepared for non-decalcified histologic and histomorphometric analysis. It was cut and polished to a thickness of 45 µm using a

Figure 2a: At 5 days following place-ment of ß-TCP combined with type I collagen in the alveolar socket, the socket opening is covered with fibrin.

Figure 2b: At 7 days, the extraction socket is covered with healing gingival tissue.

Figure 2c: Periapical radiograph taken 7 days after insertion of ß-TCP combined with type I collagen.

Figure 2d: The postextraction healed gingival wound 4 months after alveolar socket preservation.

Figure 2e: Periapical radiograph taken 9 months following socket preservation showing complete bone fill of the socket.

Figure 2f: Exposure of the alveolar bone for dental implant placement 9 months after alveolar socket preservation. Newly formed bone is solid and there are no vis-ible signs of particles.

Figure 2g: Test of implant position in the preservation area. No reduction in vertical bone height was recorded when the 9-month measurements were made and subsequently compared with baseline measurements at tooth extraction.

Figure 2h: Titanium implant immedi-ately after placement, positioned within the bone of the healed socket 9 months postextraction.

514 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 •

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the gold standard for grafting procedures, limitations, such as donor site morbidity from bone graft harvesting techniques,7 have stimulated the search for suitable syn-thetic grafting materials. Although barrier membranes may be used to guide bone regeneration, wound dehis-cence may lead to early exposure and infection of the membrane followed by reduction in the volume and quality of bone.8,9

Beta-tricalcium phosphate (β-TCP), a synthetic allo-plastic material, has been used for bone regeneration in a variety of surgical procedures with satisfactory clin-ical and histologic results in both animal models10,11 and human trials.12,13 β-TCP may be a suitable bone substitute that will biodegrade and be replaced by newly mineral- izing bone tissue without fibrous tissue proliferation.12 Bony regeneration has been reported in cases where β-TCP was used without a barrier membrane in patients undergoing sinus floor elevation and mandibular cyst re-moval.12 It is also possible to combine β-TCP with platelet-rich plasma, other growth factors or collagen to potentially accelerate the process of bone regeneration.14,15

There have been no reports on the use of β-TCP com-bined with type I collagen for postextraction socket preservation without the use of a barrier membrane or mucoperiosteal flap to cover the implanted material. The purpose of this article is to present clinical, radio-

graphic, histologic and histomorphometric results for a patient treated with β-TCP in combination with type I collagen for alveolar preservation before dental implant placement.

Case ReportA 28-year-old healthy male non-smoker with good

oral hygiene required the extraction of a left maxillary second premolar (tooth 25) before placement of a dental implant for prosthodontic rehabilitation (Fig. 1a). The tooth had to be extracted as it was severely broken down (Fig. 1b). The alveolar preservation protocol was approved by the institution’s ethical review board and written in-formed consent was obtained from the patient after the risks and benefits were explained to him.

After administration of local anesthesia, an intrasul-cular incision was made to raise a distal papilla and marginal gingiva. This exposed the marginal bone to allow visualization and measurement of the alveolar bone level (Fig. 1c). Extraction of the tooth was performed using a straight elevator and forceps without the eleva-tion of flaps. After extraction of the tooth, the socket was thoroughly curetted. β-TCP with type I collagen (RTR Cone, Septodont, Saint-Maur-des-Fossés, France) was placed in the alveolar socket occupying the space from

Figure 1a: Periapical radiograph of deteri-orated left maxillary second premolar before extraction.

Figure 1b: Remnant of the maxillary second premolar structure with extensive coronal destruction.

Figure 1c: Determination of the cre-stal alveolar bone level before socket preservation.

Figure 1d: Placement of ß-TCP combined with type I collagen (RTR Cone) at the extraction site.

Figure 1e: ß-TCP combined with type I collagen implant secured with a single suture without a barrier membrane or mucoperiosteal flap.

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cutting–grinding system (Exakt Technologies, Oklahoma City, Okla.) and stained with Stevenel’s blue and Van Gieson’s picro fuchsin. The parameters evaluated included the total area of the core, the percentage of new bone formation, the percentage of residual graft and the per-centage of fibrous tissue. All parameters were evaluated by analyzing digital images in the NIH Image Program (National Institutes of Health, Bethesda, Md).

Clinically, healing was uneventful. By the seventh day, the socket was completely covered with gingiva. During the 9 months of observation, no loss of material, no signs of infection, exudation or fistula formation at the area of the extraction and ridge preservation wound were noted. Measurement of the alveolar ridge on the day of implant placement revealed slight horizontal bone resorption, but no change in the vertical dimension of the alveolar ridge. The buccopalatal dimension of the alveolar socket was 12 mm before RTR Cone placement and 10 mm after 9 months. The alveolar crestal bone level was 3 mm below the cementoenamel junction of the mesial aspect of the left first molar before RTR Cone placement and 9 months following the placement. Clinically, no particles of ma-terial were visible and the bone was found to be smooth and solid when prepared for implant insertion (Fig. 2f).

Radiographically, by the fourth month of follow-up, the alveolar socket appeared to be filled with radiodense bone tissue except for the most cervical portion of the alveolus. By 9 months postextraction, the cervical radio-lucency had disappeared and uniform radiodense bone was found throughout the healing extraction socket (Fig. 2e).

Histologically, a great deal of active new bone forma-tion was noted (Fig. 3a). This was apparent throughout

the biopsy core (Fig. 3b) as large, irregular lacunae with active osteoblastic rimming. In some areas, new bone deposition was associated with residual β-TCP particles. It appeared that resorbing β-TCP was present as dispersed particles. No residual collagen was noted in proximity to the β-TCP, and no fibrous tissue or inflammatory cel-lular infiltration was observed. Histomorphometric an-alysis showed the composition of the sample to be 62.6% mineralized new bone, 21.1% bone marrow and 16.3% residual β-TCP graft.

Implant placement and postoperative healing were uneventful. At follow-up 18 months after prosthodontic treatment and loading, the implant was stable and sur-rounded with healthy tissue. There were no complaints or complications during this period of observation.

DiscussionThere are several reasons to consider preservation

of the alveolar socket immediately following tooth extraction. One reason for placing a graft of a synthetic biomaterial is to stabilize the coagulum within the socket and avoid possible reduction of the hard tissue volume required for bone regeneration. Although vertical bone resorption can be expected as part of the physiologic pattern of bone healing after tooth extraction,3 in our patient no reduction in the vertical dimension of the alveolar ridge had occurred 9 months after tooth extraction. The ridge width (12 mm) did not change either.

Another reason for placing a graft into an extrac-tion socket is to provide a scaffold for the in-growth of cellular and vascular components to form new bone of acceptable quality and quantity. In our patient, the total

Figure 3a: Photomicrograph of a biopsy core taken 9 months after placement of ß-TCP combined with type I collagen (RTR Cone) without a barrier membrane. Good trabecular connectivity with large, irregular lacunae of the young mineralized bone and bone marrow can be seen. ×40 magnifica-tion. Stevenel’s blue and Van Gieson’s picro fuchsin staining.

Figure 3b: High-power image of a biopsy core taken 9 months after socket preserva-tion. Residual ß-TCP and various sizes of dispersed particles are being incorporated into new bone. Large irregular lacunae appear to include ß-TCP. ×200 magnifica-tion. Stevenel’s blue and Van Gieson’s picro fuchsin stain.

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the gold standard for grafting procedures, limitations, such as donor site morbidity from bone graft harvesting techniques,7 have stimulated the search for suitable syn-thetic grafting materials. Although barrier membranes may be used to guide bone regeneration, wound dehis-cence may lead to early exposure and infection of the membrane followed by reduction in the volume and quality of bone.8,9

Beta-tricalcium phosphate (β-TCP), a synthetic allo-plastic material, has been used for bone regeneration in a variety of surgical procedures with satisfactory clin-ical and histologic results in both animal models10,11 and human trials.12,13 β-TCP may be a suitable bone substitute that will biodegrade and be replaced by newly mineral- izing bone tissue without fibrous tissue proliferation.12 Bony regeneration has been reported in cases where β-TCP was used without a barrier membrane in patients undergoing sinus floor elevation and mandibular cyst re-moval.12 It is also possible to combine β-TCP with platelet-rich plasma, other growth factors or collagen to potentially accelerate the process of bone regeneration.14,15

There have been no reports on the use of β-TCP com-bined with type I collagen for postextraction socket preservation without the use of a barrier membrane or mucoperiosteal flap to cover the implanted material. The purpose of this article is to present clinical, radio-

graphic, histologic and histomorphometric results for a patient treated with β-TCP in combination with type I collagen for alveolar preservation before dental implant placement.

Case ReportA 28-year-old healthy male non-smoker with good

oral hygiene required the extraction of a left maxillary second premolar (tooth 25) before placement of a dental implant for prosthodontic rehabilitation (Fig. 1a). The tooth had to be extracted as it was severely broken down (Fig. 1b). The alveolar preservation protocol was approved by the institution’s ethical review board and written in-formed consent was obtained from the patient after the risks and benefits were explained to him.

After administration of local anesthesia, an intrasul-cular incision was made to raise a distal papilla and marginal gingiva. This exposed the marginal bone to allow visualization and measurement of the alveolar bone level (Fig. 1c). Extraction of the tooth was performed using a straight elevator and forceps without the eleva-tion of flaps. After extraction of the tooth, the socket was thoroughly curetted. β-TCP with type I collagen (RTR Cone, Septodont, Saint-Maur-des-Fossés, France) was placed in the alveolar socket occupying the space from

Figure 1a: Periapical radiograph of deteri-orated left maxillary second premolar before extraction.

Figure 1b: Remnant of the maxillary second premolar structure with extensive coronal destruction.

Figure 1c: Determination of the cre-stal alveolar bone level before socket preservation.

Figure 1d: Placement of ß-TCP combined with type I collagen (RTR Cone) at the extraction site.

Figure 1e: ß-TCP combined with type I collagen implant secured with a single suture without a barrier membrane or mucoperiosteal flap.

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volume of newly formed bone was 83.67% including both mineralized bone and bone marrow when β-TCP with type I collagen was used without a barrier membrane or mucoperiosteal flap.

The results in this case show that β-TCP particles in the extraction socket are osteoconductive. When particles of β-TCP are mixed with the blood clot and surrounded by the bony walls of the alveolar socket, osteogenic cells, including undifferentiated mesenchymal stem cells, start migrating from the existing bone surface between and over the sur-face of the particles, stimulated mostly by an adhesive glycoprotein, fibronectine, a component of the forming blood clot.12,13 In addition, type I collagen combined with β-TCP promotes osteogenesis by supporting osteoblastic differentiation and proliferation.16,17 Type I collagen has been shown to accelerate the healing process in bone defects in animals.16 Complete bone healing was noted in animals after 3 months, whereas defects in the control group took 5 months to fill with new bone. The combination of β-TCP and type I collagen in an inte-grated structure, such as an RTR Cone as used in our study, has demonstrated osteoconductivity, which facili-tates bone formation.15

Significant resorption of the β-TCP particles is expected 3–6 months after placement.10 At 9 months after alveolar socket preservation, the small residual amount of β-TCP graft did not compromise placement of the osseointegrated dental implant. Moreover, β-TCP particles become well incorporated into new bone formation creating a dense cancellous network. This may improve the biologic ability to withstand loading forces transmitted by implants placed in that site. Biodegradation of β-TCP occurs by both osteoclastic activity and chemical dissolution by tissue fluids.18 β-TCP is a highly porous material and dissolved β-TCP particles can be incorporated into the newly min-eralized bone and the lacunar–canalicular system of osteocytes19 as well as into the bone marrow or marginal osteoid.

An important factor in this case is that neither a barrier membrane nor a mucoperiosteal flap was used to cover the alveolar postextraction socket filled with synthetic material. Instead, the β-TCP in combination with type I collagen was left uncovered to heal spon-taneously. At 7 days, the process of epithelialization was complete and the socket was covered without clin-ical complications. Several possible mechanisms may explain the apparent blockade of fibrous tissue in-growth into the porous structure of the β-TCP granules: inhibition of fibroblastic proliferation by β-TCP and its metabolites during dissolution of β-TCP particles20; a local decrease in pH during dissolution of material13; or direct chemical bonding of β-TCP with bone through a reaction between calcium ions in the β-TCP particle

and carboxyl groups in the collagen polypeptide chains.15,19

This case report suggests that a cone of biomaterial, composed of β-TCP combined with type I collagen, can prevent alveolar crest resorption following tooth ex-traction without the use of a barrier membrane or a mucoperiosteal flap. Formation of new bone of accept-able quality and quantity permitted the placement of an osseointegrated dental implant. Further study of this material and this protocol is needed and a case series is currently underway. a

THE AUTHORS

Dr. Brkovic is an assistant professor in the Clinic of Oral Surgery, School of Dentistry, University of Belgrade, Belgrade, Serbia, and Stoneman Fellow in Pediatric Oral and Maxillofacial Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario.

Mr. Prasad is an assistant professor in the Hard Tissue Research Laboratory, School of Dentistry, University of Minnesota, Minneapolis, Minnesota.

Dr. Konandreas maintains a private practice in Athens, Greece.

Dr. Milan is an assistant professor in the department of oral surgery, faculty of dentistry, University of Pancevo, Pancevo, Serbia.

Dr. Antunovic maintains a private practice in Belgrade, Serbia.

Dr. Sándor is a professor of oral and maxillofacial surgery, University of Toronto, Toronto, Ontario; professor at the Regea Institute for Regenerative Medicine, University of Tampere, Tampere, Finland; and docent in oral and maxillofacial sur-gery, University of Oulu, Oulu, Finland.

Dr. Rohrer is a professor in the Hard Tissue Research Laboratory, School of Dentistry, University of Minnesota, Minneapolis, Minnesota.

Correspondence to: Professor George K.B. Sándor, The Hospital for Sick Children, S-525, 555 University Avenue, Toronto ON M5G 1X8.

Acknowledgments: The authors wish to thank Septodont, France, for finan-cial assistance and for donating the clinical material used in this studty.

The authors have no declared financial interests in any company manufac-turing the types of products mentioned in this article.

This article has been peer reviewed.

514 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 •

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the gold standard for grafting procedures, limitations, such as donor site morbidity from bone graft harvesting techniques,7 have stimulated the search for suitable syn-thetic grafting materials. Although barrier membranes may be used to guide bone regeneration, wound dehis-cence may lead to early exposure and infection of the membrane followed by reduction in the volume and quality of bone.8,9

Beta-tricalcium phosphate (β-TCP), a synthetic allo-plastic material, has been used for bone regeneration in a variety of surgical procedures with satisfactory clin-ical and histologic results in both animal models10,11 and human trials.12,13 β-TCP may be a suitable bone substitute that will biodegrade and be replaced by newly mineral- izing bone tissue without fibrous tissue proliferation.12 Bony regeneration has been reported in cases where β-TCP was used without a barrier membrane in patients undergoing sinus floor elevation and mandibular cyst re-moval.12 It is also possible to combine β-TCP with platelet-rich plasma, other growth factors or collagen to potentially accelerate the process of bone regeneration.14,15

There have been no reports on the use of β-TCP com-bined with type I collagen for postextraction socket preservation without the use of a barrier membrane or mucoperiosteal flap to cover the implanted material. The purpose of this article is to present clinical, radio-

graphic, histologic and histomorphometric results for a patient treated with β-TCP in combination with type I collagen for alveolar preservation before dental implant placement.

Case ReportA 28-year-old healthy male non-smoker with good

oral hygiene required the extraction of a left maxillary second premolar (tooth 25) before placement of a dental implant for prosthodontic rehabilitation (Fig. 1a). The tooth had to be extracted as it was severely broken down (Fig. 1b). The alveolar preservation protocol was approved by the institution’s ethical review board and written in-formed consent was obtained from the patient after the risks and benefits were explained to him.

After administration of local anesthesia, an intrasul-cular incision was made to raise a distal papilla and marginal gingiva. This exposed the marginal bone to allow visualization and measurement of the alveolar bone level (Fig. 1c). Extraction of the tooth was performed using a straight elevator and forceps without the eleva-tion of flaps. After extraction of the tooth, the socket was thoroughly curetted. β-TCP with type I collagen (RTR Cone, Septodont, Saint-Maur-des-Fossés, France) was placed in the alveolar socket occupying the space from

Figure 1a: Periapical radiograph of deteri-orated left maxillary second premolar before extraction.

Figure 1b: Remnant of the maxillary second premolar structure with extensive coronal destruction.

Figure 1c: Determination of the cre-stal alveolar bone level before socket preservation.

Figure 1d: Placement of ß-TCP combined with type I collagen (RTR Cone) at the extraction site.

Figure 1e: ß-TCP combined with type I collagen implant secured with a single suture without a barrier membrane or mucoperiosteal flap.

35

518 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 •

––– Sándor ––– ClinicalP r a c t i c e

References1. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-longitudinal study covering 25 years. 1972. J Prosthet Dent 2003; 89(5):427–35.

2. Araújo MG, Sukekava F, Wennström JL, Lindhe J. Ridge alterations fol-lowing implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol 2005; 32(6):645–52.

3. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical proced-ures, and outcomes. Int J Oral Maxillofac Implants 2004; 19 Suppl:12–25.

4. Nair Pn PR, Schug J. Observation on healing of human tooth extraction sockets implanted with bioabsorbable polylactic-polyglycolic acids (PLGA) copolymer root replicas: a clinical, radiographic, and histologic follow-up report of 8 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 97(5):559–69.

5. Cardaropoli G, Araújo M, Hayacibara R, Sukekava F, Lindhe J. Healing of extraction sockets and surgically produced — augmented and non-aug-mented — defects in the alveolar ridge. An experimental study in the dog. J Clin Periodontol 2005; 32(5):435–40.

6. Boix D, Weiss P, Gauthier O, Guicheux J, Bouler JM, Pilet P, and others. Injectable bone substitute to preserve alveolar ridge resorption after tooth extraction: a study in dog. J Mater Sci Mater Med 2006; 17(11):1145–52. Epub 2006 Nov 22.

7. Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local onlay augmentation: comparison of donor site morbidity and complica-tions. Clin Implant Dent Relat Res 2003; 5(3):154–60.

8. Malchiodi L, Scarano A, Quaranta M, Piattelli A. Rigid fixation by means of titanium mesh in edentulous ridge expansion for horizontal ridge augmenta-tion in the maxilla. Int J Oral Maxillofac Implants 1998; 13(5):701–5.

9. Artzi Z, Dayan D, Alpern Y, Nemcovsky CE. Vertical ridge augmentation using xenogenic material supported by a configured titanium mesh: clinico-histopathologic and histochemical study. Int J Oral Maxillofac Implants 2003; 18(3):440–6.

10. Artzi Z, Weinreb M, Givol N, Rohrer MD, Nemcovsky CE, Prasad HS, and other. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study and morphometric analysis. Int J Oral Maxillfac Implants 2004; 19(3):357–68.

11. Haddad AJ, Peel SA, Clokie CM, Sándor GK. Closure of rabbit calvarial critical-sized defects using protective composite allogeneic and alloplastic bone substitutes. J Craniofac Surg 2006; 17(5):926–34.

12. Zerbo IR, Bronckers AL, de Lange GL, van Beek GJ, Burger EH. Histology of human alveolar bone regeneration with a porous tricalcium phosphate. A report of two cases. Clin Oral Implants Res 2001; 12(4):379–84. [Article in English, French, German]

13. Zerbo IR, Bronckers AL, de Lange G, Burger EH. Localisation of osteo-genic cells and osteoplastic cells in porous beta-tricalcium phosphate par-ticles used for human maxillary sinus floor elevation. Biomaterials 2005; 26(12):1445–51.

14. Wiltfang J, Schlegel KA, Schultze-Mosgau S, Nkenke E, Zimmermann R, Kessler P. Sinus floor augmentation with beta-tricalciumphosphate (beta-TCP): does platelet-rich plasma promote its osseous integration and deg-radation? Clin Oral Implants Res 2003; 14(2):213–8.

15. Zou C, Weng W, Deng X, Cheng K, Liu X, Du P, and others. Preparation and characterization of porous beta-tricalcium phosphate/collagen compos-ites with an integrated structure. Biomaterials 2005; 26(6):5276–84.

16. Güngörmüs M, Kaya O. Evaluation of the effect of heterologous type I collagen on healing of bone defects. J Oral Maxillofac Surg 2002; 60(5):541–5.

17. Ignatius A, Blessing H, Liedert A, Schmidt C, Neidlinger-Wilke C, Kaspar D, and others. Tissue engineering of bone: effects of mechanical strain on osteoblastic cells in type I collagen matrices. Biomaterials 2005; 26(3):311–8.

18. Lu JX, Gallur A, Flautre B, Anselme K, Descamps M, Thierry B, and other. Comparative study of tissue reactions to calcium phosphate ceramics among cancellous, cortical, and medullar bone sites in rabbits. J Biomed Mater Res 1998; 42(3):357–67.

19. Fujita R, Yokoyama A, Nodasaka Y, Kohgo T, Kawasaki T. Ultrastructure of ceramic-bone interface using hydroxyapatite and beta-tricalcium phos-phate ceramics and replacement mechanism of beta-tricalcium phosphate in bone. Tissue Cell 2003; 35(6):427–40.

20. Pioletti DP, Takei H, Lin T, van Landuyt P, Ma QJ, Kwon SY, and others. The effects of calcium phosphate cement particles on osteoblast functions. Biomaterials 2000; 21(11):1103–14.

518 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 •

––– Sándor ––– ClinicalP r a c t i c e

References1. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-longitudinal study covering 25 years. 1972. J Prosthet Dent 2003; 89(5):427–35.

2. Araújo MG, Sukekava F, Wennström JL, Lindhe J. Ridge alterations fol-lowing implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol 2005; 32(6):645–52.

3. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical proced-ures, and outcomes. Int J Oral Maxillofac Implants 2004; 19 Suppl:12–25.

4. Nair Pn PR, Schug J. Observation on healing of human tooth extraction sockets implanted with bioabsorbable polylactic-polyglycolic acids (PLGA) copolymer root replicas: a clinical, radiographic, and histologic follow-up report of 8 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 97(5):559–69.

5. Cardaropoli G, Araújo M, Hayacibara R, Sukekava F, Lindhe J. Healing of extraction sockets and surgically produced — augmented and non-aug-mented — defects in the alveolar ridge. An experimental study in the dog. J Clin Periodontol 2005; 32(5):435–40.

6. Boix D, Weiss P, Gauthier O, Guicheux J, Bouler JM, Pilet P, and others. Injectable bone substitute to preserve alveolar ridge resorption after tooth extraction: a study in dog. J Mater Sci Mater Med 2006; 17(11):1145–52. Epub 2006 Nov 22.

7. Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local onlay augmentation: comparison of donor site morbidity and complica-tions. Clin Implant Dent Relat Res 2003; 5(3):154–60.

8. Malchiodi L, Scarano A, Quaranta M, Piattelli A. Rigid fixation by means of titanium mesh in edentulous ridge expansion for horizontal ridge augmenta-tion in the maxilla. Int J Oral Maxillofac Implants 1998; 13(5):701–5.

9. Artzi Z, Dayan D, Alpern Y, Nemcovsky CE. Vertical ridge augmentation using xenogenic material supported by a configured titanium mesh: clinico-histopathologic and histochemical study. Int J Oral Maxillofac Implants 2003; 18(3):440–6.

10. Artzi Z, Weinreb M, Givol N, Rohrer MD, Nemcovsky CE, Prasad HS, and other. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study and morphometric analysis. Int J Oral Maxillfac Implants 2004; 19(3):357–68.

11. Haddad AJ, Peel SA, Clokie CM, Sándor GK. Closure of rabbit calvarial critical-sized defects using protective composite allogeneic and alloplastic bone substitutes. J Craniofac Surg 2006; 17(5):926–34.

12. Zerbo IR, Bronckers AL, de Lange GL, van Beek GJ, Burger EH. Histology of human alveolar bone regeneration with a porous tricalcium phosphate. A report of two cases. Clin Oral Implants Res 2001; 12(4):379–84. [Article in English, French, German]

13. Zerbo IR, Bronckers AL, de Lange G, Burger EH. Localisation of osteo-genic cells and osteoplastic cells in porous beta-tricalcium phosphate par-ticles used for human maxillary sinus floor elevation. Biomaterials 2005; 26(12):1445–51.

14. Wiltfang J, Schlegel KA, Schultze-Mosgau S, Nkenke E, Zimmermann R, Kessler P. Sinus floor augmentation with beta-tricalciumphosphate (beta-TCP): does platelet-rich plasma promote its osseous integration and deg-radation? Clin Oral Implants Res 2003; 14(2):213–8.

15. Zou C, Weng W, Deng X, Cheng K, Liu X, Du P, and others. Preparation and characterization of porous beta-tricalcium phosphate/collagen compos-ites with an integrated structure. Biomaterials 2005; 26(6):5276–84.

16. Güngörmüs M, Kaya O. Evaluation of the effect of heterologous type I collagen on healing of bone defects. J Oral Maxillofac Surg 2002; 60(5):541–5.

17. Ignatius A, Blessing H, Liedert A, Schmidt C, Neidlinger-Wilke C, Kaspar D, and others. Tissue engineering of bone: effects of mechanical strain on osteoblastic cells in type I collagen matrices. Biomaterials 2005; 26(3):311–8.

18. Lu JX, Gallur A, Flautre B, Anselme K, Descamps M, Thierry B, and other. Comparative study of tissue reactions to calcium phosphate ceramics among cancellous, cortical, and medullar bone sites in rabbits. J Biomed Mater Res 1998; 42(3):357–67.

19. Fujita R, Yokoyama A, Nodasaka Y, Kohgo T, Kawasaki T. Ultrastructure of ceramic-bone interface using hydroxyapatite and beta-tricalcium phos-phate ceramics and replacement mechanism of beta-tricalcium phosphate in bone. Tissue Cell 2003; 35(6):427–40.

20. Pioletti DP, Takei H, Lin T, van Landuyt P, Ma QJ, Kwon SY, and others. The effects of calcium phosphate cement particles on osteoblast functions. Biomaterials 2000; 21(11):1103–14.

514 JCDA • www.cda-adc.ca/jcda • July/August 2008, Vol. 74, No. 6 •

––– Sándor –––

the gold standard for grafting procedures, limitations, such as donor site morbidity from bone graft harvesting techniques,7 have stimulated the search for suitable syn-thetic grafting materials. Although barrier membranes may be used to guide bone regeneration, wound dehis-cence may lead to early exposure and infection of the membrane followed by reduction in the volume and quality of bone.8,9

Beta-tricalcium phosphate (β-TCP), a synthetic allo-plastic material, has been used for bone regeneration in a variety of surgical procedures with satisfactory clin-ical and histologic results in both animal models10,11 and human trials.12,13 β-TCP may be a suitable bone substitute that will biodegrade and be replaced by newly mineral- izing bone tissue without fibrous tissue proliferation.12 Bony regeneration has been reported in cases where β-TCP was used without a barrier membrane in patients undergoing sinus floor elevation and mandibular cyst re-moval.12 It is also possible to combine β-TCP with platelet-rich plasma, other growth factors or collagen to potentially accelerate the process of bone regeneration.14,15

There have been no reports on the use of β-TCP com-bined with type I collagen for postextraction socket preservation without the use of a barrier membrane or mucoperiosteal flap to cover the implanted material. The purpose of this article is to present clinical, radio-

graphic, histologic and histomorphometric results for a patient treated with β-TCP in combination with type I collagen for alveolar preservation before dental implant placement.

Case ReportA 28-year-old healthy male non-smoker with good

oral hygiene required the extraction of a left maxillary second premolar (tooth 25) before placement of a dental implant for prosthodontic rehabilitation (Fig. 1a). The tooth had to be extracted as it was severely broken down (Fig. 1b). The alveolar preservation protocol was approved by the institution’s ethical review board and written in-formed consent was obtained from the patient after the risks and benefits were explained to him.

After administration of local anesthesia, an intrasul-cular incision was made to raise a distal papilla and marginal gingiva. This exposed the marginal bone to allow visualization and measurement of the alveolar bone level (Fig. 1c). Extraction of the tooth was performed using a straight elevator and forceps without the eleva-tion of flaps. After extraction of the tooth, the socket was thoroughly curetted. β-TCP with type I collagen (RTR Cone, Septodont, Saint-Maur-des-Fossés, France) was placed in the alveolar socket occupying the space from

Figure 1a: Periapical radiograph of deteri-orated left maxillary second premolar before extraction.

Figure 1b: Remnant of the maxillary second premolar structure with extensive coronal destruction.

Figure 1c: Determination of the cre-stal alveolar bone level before socket preservation.

Figure 1d: Placement of ß-TCP combined with type I collagen (RTR Cone) at the extraction site.

Figure 1e: ß-TCP combined with type I collagen implant secured with a single suture without a barrier membrane or mucoperiosteal flap.

36

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

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

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

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

alveolar ridge augmentation.7, 8

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

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

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

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

Introduction

37

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

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

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

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

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

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

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

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

Fig. 3: Panoramic X-ray.

38

Fig. 4: Atraumatic extraction.

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

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

A B C

Fig. 8: Clinical examination (12 months).

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

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

39

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

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

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

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

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

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

A B C

A

C

B

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

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

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

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

A B C

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

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

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

Implant activation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

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

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

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

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

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

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

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

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

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

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32

PERIODONTAL DEFECTS – 3 ARTICLES

Comparative evaluation of clinical efficacy of β-tricalcium phosphate (Septodont-RTR)™ alone and in combination with platelet rich plasma for treatment of intrabony defects in chronic periodontitis Jyostna Pinipe, Narendra Babu Mandalapu, Sesha Reddy Manchala, Satheesh Mannem, N.V.S. Sruthima Gottumukkala, and Suneetha Koneru J Indian Soc Periodontol. 2014 May-Jun; 18(3): 346–351.

The clinical impact of PRP and ß-TCP in the treatment of infrabony defects Aleksic Z, Jankovic S Journal of clinical periodontology, 2006, 33, supp7, 104

β-TCP (R.T.R.) and aggressive periodontitis Prof. D. Bouziane Septodont Case Studies Collection n°8, June 2014, p14-21

32

PERIODONTAL DEFECTS – 3 ARTICLES

Comparative evaluation of clinical efficacy of β-tricalcium phosphate (Septodont-RTR)™ alone and in combination with platelet rich plasma for treatment of intrabony defects in chronic periodontitis Jyostna Pinipe, Narendra Babu Mandalapu, Sesha Reddy Manchala, Satheesh Mannem, N.V.S. Sruthima Gottumukkala, and Suneetha Koneru J Indian Soc Periodontol. 2014 May-Jun; 18(3): 346–351.

The clinical impact of PRP and ß-TCP in the treatment of infrabony defects Aleksic Z, Jankovic S Journal of clinical periodontology, 2006, 33, supp7, 104

β-TCP (R.T.R.) and aggressive periodontitis Prof. D. Bouziane Septodont Case Studies Collection n°8, June 2014, p14-21

2

46

Aleksic, Z., Jankovic, S. (2006), The clinical impact of PRP and ßTCP in the treatment of infrabony defects. Journal of Clinical Periodontology, 33, supp.7, 104.

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

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

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

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

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

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

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

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

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

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

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

graphy re-assessments over four years

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

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

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

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

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

Materials & methods

Fig. 3: Inflammatory aspect

Fig. 4: Terminal lysis at 21 and 11

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

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

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

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

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

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

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

(Fig. 8 & 9)

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

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

• At this stage the migration treatment wasperformed.

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

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

13

Case Report no.1

Fig. 5: Clinical inflammatory aspect

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

Fig. 7: Severe infrabony defectat the level of 21

Fig. 8: Incisions - raising of aflap

Fig. 9: Insertion of bone substitute

Fig. 10: Result at1 year

Fig. 11: DFO treatment of migration at1 year

Fig. 12: Stabilisation of bonegain

Fig. 13: RVG 50% bone gain at4 years

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

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

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

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

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

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

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

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

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

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

Fig. 16: Incision and raising of flap

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

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

The radiography X-ray shows an infrabonylesion associated with a class 3 bifurcationinvolvement (Fig. 25). At 15 days the fillingmaterial is in place (Fig. 26).

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

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

treatment which consisted in a combinationof amoxicillin and metronidazole during10 days

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

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

Fig. 23: Clinical aspect

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

Fig. 25: Before treatment

Fig. 26: 15 days after the filling

Fig. 27: Result at 4 years

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

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

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

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

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

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

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

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

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

showed a bone gain with filling of infrabonylesions.

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

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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BONE AUGMENTATION – 2 ARTICLES

Clinical long-term results and histological examinations for bone regeneration with β-tricalcium phosphate and insertion of implants R. Füßinger and K. Füßinger Dentistry Clinical, 2006 June 22, p15-16

Bone augmentation with titanium mesh and β-tricalcium phosphate Brkovic B, Milan R, Jurisic M, Danilovic V, Clinical Oral Implants Research, volume 17 issue 4 page xvii - August-2006

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Brkovic B, Radulovic M, Jurisic M, Danilovic V Clinical Oral Implants Research,Volume 17 Issue 4 Page xvii - August 2006

237 Poster – Topic : Tissue AugmentationBone augmentation with titanium mesh and ß tricalcium phosphateBrkovic B1, Radulovic M2, Jurisic M1, Danilovic V3

The purpose of this report was to present a case of vertical and horizontal alveolar ridge augmentation in the maxilla using ß tricalcium phosphate (ßTCP) associated with a titanium mesh.A healthy 38-year-old woman was scheduled for bone regeneration therapy of the premolar maxillary area. Full-thickness flap was elevated to expose the bone on the palatal and buccal aspect of alveolar ridge. Firstly grafted area was protected with titanium mesh (Module® Mesh, Straumann, Switzerland), which was fixed by screws in the form to create desired dimension of alveolar ridge. Granules of ßTCP (RTR Syringe®, Septodont, France) were placed between the host bone and mesh through the mesh perforations. Collagen membrane (BioGide®, Geistlich Pharma, Switzerland) was used to cover surgical area before suture. After 6 months, a second surgery was performed for removal of titanium mesh, bone biopsy and implant insertion. The material for histological analysis was decalcified and stained with haematoxylin and eosin.The new ridge dimension was increased horizontally and vertically in comparison with the initial level. Particles of ßTCP were partly detectable in the central part of augmented region. Histological analysis revealed that 6-months healing period resulted in appearance of new ossification centres with high proportion of osteocytes. Osteoblasts, osteoid and ßTCP particles were seen in a close proximity to newly formed bone. The cells of inflammation were not present.Results of the present report support the efficacy of ßTCP as grafting material for minor ridge preservation in combination with titanium mesh.

1 Clinic of Oral Surgery, Dental School, University of Belgrade, Belgrade, Serbia and Montenegro, 2 Department of Oral surgery, Faculty of Stomatology, Pancevo, Pancevo, Serbia and Montenegro, 3 Department of Oral Histology and Embriology, Dental School, University of Belgrade, Belgrade, Serbia and Montenegro

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MULTI- INDICATIONS – 3 ARTICLES

Biomaterials for bone regeneration in oral surgery: a multicenter study to evaluate the clinical application of R.T.R. (β-tricalcium phosphate) P. Brunamonti, G. Galvagna, M. Galli, M. Labanca Septodont Case Studies Collection n°7, 2014 March, p4-11

Use of ß-tricalcium phosphate for bone regeneration in oral surgery P. Brunamonti, G. Galvagna, M. Galli, M. Labanca Septodont Case Studies Collection n°9, 2014 October, p4-13

Alloplastic Grafts -Beta-tricalcium phosphate M.E. García-Briseño Septodont Case Studies Collection n°9, 2014 October, p14-19

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

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

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

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

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

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

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

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

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

Introduction

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R.T.R. (ß-tricalcium phosphate)

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

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

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

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

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

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

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

to new cells in the differentiation process.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

in areas with deficiencies in bone or post-extraction

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

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

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

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

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

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

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

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

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

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

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

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

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

Case Report no.2

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

through adequately prepared surrounding bone(cortical perforation)

- stabilization and maintenance of volume under-neath the membrane

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

in 1980 nyman and Karring first introduced theconcept of guided tissue regeneration (gtr) of

Use of ß-tricalcium phosphate for bone regeneration in oral surgeryA multicenter study to evaluate the clinical applications of R.T.R. (Resorbable Tissue Replacement) Giuseppe Galvagna: Private practice, catania, italyPaolo Brunamonti Binello: consultant Professor, university of genoaMassimo Galli: Private practice, Pistoia, italyMauro Labanca: consultant Professor in oral surgery and anatomy, milan, italy

Introduction

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

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

Graft biomaterials

the alloplastic biomaterials available on themarket represent an excellent alternative toautologous bone graft and are classified intotwo large groups: bioinert and bioactive, accor-ding to their interaction when they come intocontact with the receiving site.the main requirement of a synthetic biomaterialis to have a surface porosity that must promotecolonization and development within its structure.these porosities must measure between 200/400microns in diameter (lynch et al., 2000; bauerand muschler, 2000). synthetic biomaterialshave been the subject of many studies, thoughtheir long term results have not always beenconsidered. (1-2-3)today, osteoblastic cells or bone morphogeneticproteins (bmP obtained with in vitro cultures)can be added to a graft material (4-5) to enhanceits osteoinductive and osteoconductive abilitiesand therefore reduce the time required for cellscolonization. (6-7-8)among alloplastic biomaterials, ß-tricalciumphosphate is the one that mostly displays astable bond with bone neoformation; indeed,its characteristics have made it suitable foruse in orthopedics since the early 1900s. inthe presence of H2o it becomes instable,turning into hydroxyapatite, and this characte-ristic makes it suitable as an osteoconductivematerial (coetree, 1980, De leonardis andPecora, 1999; 2000).ß-tcP is characterized by a lower ca/P ratio,which makes it more soluble than natural apatite.the beta form is commonly obtained by mixingcalcitis (cc) and dibasic calcium phosphateanhydrous (DcPa). the product obtained israpidly cooled, and alfa-tcP is obtained. conver-sely, extended repeat baking at 800/950°cresults in the beta form (9-12-13).multiple studies conducted on the tc and boneinteraction have shown that histological exami-nation at four months shows an initial boneneoformation in the intergranular spaces and inthe surface porosity that helps guided boneformation. indeed, the granules are reabsorbedby phagocytosis, releasing ca/mg and phos-

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

R.T.R.

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

the micro and macro-porous r.t.r. structure,with macropores measuring between 100 and400 µm and micropores measuring less than10 µm.these morphological characteristics allow excel-lent osteogenic cell in-depth colonization andeasy compacting.

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

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

dimensions of alveolar bone • implant defects• sinus lift procedure• reconstruction of peri-implant defects• filling periodontal pockets with two or more

walls• residual cavities after oral surgery (like cyst)• filling defects after apicectomy• alveolar filling following extraction of impacted

teeth.

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

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

morphology and etiopathogenesis restrictions).

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

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

Materials and methods

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Case Report no.1Patient: female Age: 30History: odontogenic cyst in maxillary bone at 2.1. cyst was removed in october 2013. Vertical guided regeneration with resorbable membrane andr.t.r. was performed. implant placement: bone peak follow-up intraoral X-ray in consecutivemonths. 2nd surgery isQ value: 61.

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

Fig. 6: X-ray image beforegrafting.

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

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

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

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

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

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

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

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

Fig. 16-17-18: filling the bone cavity with granular r.t.r.

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

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

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

Fig. 27-28: use of tabotamp to cover thegraft.

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

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

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

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

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

Fig. 38-39-40: the gap was filled using r.t.r.-size cone.

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

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Case Report no.5Patient: femaleAge: 64History: loss of 2.2 and 2.3 due to trauma.ct revealed a significant resorption of buccal vestibular alveolar process.two implants were placed (measuring 3.3 mm in diameter and 13 mm long) and the gap was filledwith r.t.r.re-opening was done after 5 months and evaluation of osteointegration with osstel. 2.2 showed a value of 22-isQ, and 2.3 –isQ 64.

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

Fig. 48-49: the gap between the two margin bone was filled withphosphate-tricalcium r.t.r.

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

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

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

Fig. 53-54: the isQ value confirms a goodosseointegration.

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Conclusionbased on the results obtained in the short term,the authors confirm the excellent properties ofr.t.r., both in the first weeks of healing and inthe following months, and they consider it anexcellent alternative to autologous bone grafts. no inflammatory reactions or loss of bonevolume evaluated clinically and radiographically

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

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

Fig. 55-56: the c.t. examination beforesurgery showed a residual cyst.

Fig. 57-58: after having removed the cyst,to speed up the healing time, the cavity hasbeen filled with r.t.r. granules.

Fig. 60: X-ray at 3 months.

Fig. 59: Wound at 30 days.

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Authors (left to right)Giuseppe Galvagna: Dental practitioner, catania, italyPaolo Brunamonti Binello: consultant Professor, university of genoa. galliera Hospital,genoa, italyMassimo Galli: oral surgeon, dental practitioner, Pistoia, italyMauro Labanca: Professor of oral surgery and anatomy, milan, italy

References01. labanca m., leonida a., rodella fl: natural synthetic biomaterial in Dentistry: science and ethics as

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

02. ohgushi H, caplan ai: stem cell technology and bioceramics: from cell to gene engineering. J biomedmater res 48(6): 913-927, 1999

03. anselme K: osteoblast adhesion on biomaterals. biomaterials 2000 apr; 21(7):667-81.

04. toquet J, roahanizadeh r, guicheux J, couillaud s, Passuti n, Daculsi g, Heymann D: osteogenic.Potential in vitro of human bone marrow cells cultured on macroporous biphasic

05. maddox e, Zhan m, mundy gr, Drohan Wn, burgess WH: optimizing human demineralized bone matrixfor clinical application. tissue eng 6(4): 441-448, 2000 calcium phosphate ceramic. J biomed mater res.1999 Jan; 44(1):98-108.

06. gauthier o, bouler Jm, aguado e, Pilet P, Daculsi g: macroporous biphasic calcium phosphate ceramics:influence of macropore diameter and macroporosity percentage on bone ingrowth. biomaterials 1998 Janfeb;19(1-3):133-9.

07. martinetti r, belpassi a, nataloni a, biasini V, martignani g: idrossiapatite porosa sintetica per sostituzioniossee: caratterizzazione chimico-fisica. biomateriali: atti del congresso; 51 55, roma enea, 1999

08. martinetti r, belpassi a et al.: Key engineering materials Vols. 192-195 (2001), 507-510 – Proceeding ofthe 13th int. symp. on ceramics in medicine, bologna, italy, 22-26 nov.

09. caplan ai: mesenchymal stem cells. J orthop res 9: 641-650, 199

10. nyman s, lindhe J, Karring t et rylander H: new attachment following surgical treatment of humanperiodontal disease. Journal of clinical Periodontology 9: 290-296, 1982; 39

11. Hämmerle cH, brägger u, bürgin W, lang nP: the effect of subcrestal placement of the polished surfaceof iti implants on marginal soft and hard tissues. clin oral implants res. 1996 Jun;7(2):111-9

12. chin m: Distraction osteogenesis in maxillofacial surgery. in lynch se, genco rJ, marx re (eds). tissueengineering – application in maxillofacial surgery and Periodontics. illinois; Quintessence Publishing co,inc, 1999; 147

13. arun K. garg: grafting materials in repair and restoration. in lynch se, genco rJ, marx re, (eds). tissueengineering - application in maxillofacial surgery and Periodontics. illinois; Quintessence Publishing co,inc, 1999; 83

14. scipioni a, bruschi gb, calesini g: the edentulous ridge expansion technique: a five-year study. int JPeriodont rest Dent 14: 451-459, 1994 trans tech Publications, switzerland

15. schenk rK and buser D: osseointegration: a reality. Periodontology 2000, Vol 17. 1998, 22.35

16. bauer tW and muschler gf: bone graft materials. an overview of the basic science. clin orthop relarres, 2000 feb;(371):10-27.

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

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

Modifications in the AlveolarProcess

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

Introduction

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

Alloplastic Grafts - Beta-tricalciumphosphate Presentation of clinical casesMario Ernesto García-BriseñoDDs and Professor in Periodontics - autonomous university of guadalajara (uag), mexico 

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

Periodontal bone defects

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

Tooth extraction

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

alveolus has a very high and predictable chanceof healing in a natural and healthy way withoutany intervention. the biological principle ofthe alveolus repair is based on the formationof a blood clot that covers it completely. Post-extraction healing process has been accuratelydescribed. the stages of this natural processmay be summarised in the following manner: at 30 minutes: clot; at 24 hours: formation ofblood clot and haemolysis; at 2-3 days: forma-tion of granulation tissue. at 4 days: increasein fibroblast density and epithelial proliferationover the edge of the wound and presence ofosteoclasts indicating the alveolus remodelling.at 1 week: defined vascular network and matu-ring connective tissue; osteoid formation inthe bottom of the alveolus. at 3 weeks: denseconnective tissue; full epithelial cover. at2 months: full bone formation is complete butwithout reaching the original height (15,16).

Graft Material Characteristics

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

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

Classification of graft materialsby origin

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

Beta-tricalcium phosphate

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

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

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

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

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

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

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

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

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

Fig. 4: ß-tricalcium phosphate “r.t.r.”(septodont) as a graft material.

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

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

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

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

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

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

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

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

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

Fig. 9: composite blood clot and ß-tricalcium phosphate “r.t.r.” (septodont)used as graft material prior the suture. in thearea of resorption a cone shaped ß-tricalcium phosphate “r.t.r.” (septodont)is used and in the mesial root alveolusparticles of ß-tricalcium phosphate “r.t.r.”(septodont) are used.

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Author: Dr Mario Ernesto García-Briseño DDs at universidad autónoma de guadalajara, méxico, 1976. certificate program in Periodontology at universidad nacional autónoma deméxico 1985-87.Director and Professor of the certificate program in Periodontology since 1992to date at universidad autónoma de guadalajara school of Dentistry.Professor of Periodontology at certificate programs in endodontics,orthodontics, and oral rehabilitation since 1992 at universidad autónoma de

guadalajara school of Dentistry. founder and President of the mexican association of Periodontology 1996-98. founding member and secretary of the mexican board of Periodontology 1996/2001. academy affairs coordinator college of Dental surgeons of Jalisco 2000/2004. founder and academic coordinator of the college of Periodontics gDl. national and international lecturer. Private practice in Periodontics and implant Dentistry.

References01. listgarten ma. Pathogenesis of periodontitis. J clin Periodontol. 1986; 13: 418-425.

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

03. boyne PJ. osseous repair of the postextraction alveolus in man. oral surg oral med oral Pathol 1966;21:805-813.

04. Pietrokovski J, massler m. alveolar ridge resorption following tooth extraction. J Prosthet Dent1967;17:21-27.

05. seibert Js. reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Parti. technique and wound healing. compend contin educ Dent 1983;4:437-453.

06. smiler Dg, Johnson PW, lozada Jl, et al. sinus lift grafts and endosseous implants. treatment of theatrophic posterior maxilla. Dent clin north am 1992;36:151-186.

07. lekovic V, Kenney eb, Weinlaender m, et al. a bone regenerative approach to alveolar ridge maintenancefollowing tooth extraction. report of 10 cases. J Periodontol 1997;68:563-570.

08. mellonig, Jt. autogenous and allogeneic bone grafts in Periodontal therapy. crit rev oral biol19923(4):333-352

09. Jarcho m. biomaterials aspects of calcium phosphates. Properties and applications. Dent clin north am1986;30:25–47.

10. Dhingra K. oral rehabilitation considerations for Partially edentulous Periodontal Patients JProsthodontics 21 (2012) 494–513

11. listgarten ma. Pathogenesis of periodontitis. J clin Periodontol. 1986; 13: 418-425.

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

13. Zitzmann nu, Krastl g, Walter c, et al: strategic considerations in treatment planning: deciding when totreat, extract, or replace a questionable tooth. J Prosthet Dent 2010;104:80-91

14. craddock Hl, youngsoncc, manogue m, blance a. occlusal changes following Posterior tooth loss inadults. Part 2. clinical Parameters associated with movement of teeth adjacent to the site of Posteriortooth loss J Prosthodont 2007;16:485-494.

15. amler mH. the time sequence of tissue regeneration in human extraction wounds. oral surg . 1969 27;309-318

16. boyne PJ. osseous repair of the postextraction alveolus in man. oral surg oral med oral Pathol 1966;21:805-813.

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References17. american academy of Periodontology. glossary of Periodontol terms, 4th ed. chicago: american academy

of Periodontolgy; 2001;44.

18. reynold ma, aichelmann-reidy me, branch-mays gl. regeneration of periodontal tissue: bonereplacement grafts. Dent clin north am 2010;54:55-71

19. urist mr. bone: formation by autoinduction. science 1965;150:893-899.

20. Jarcho m. biomaterials aspects of calcium phosphates. Properties and applications. Dent clin north am1986;30:25-47

21. Hollinger Jo, brekke J, gruskin e, lee D. role of bone substitutes. clin orthop 1996;mar(324):55-65

22. gross Js. bone grafting materials for dental applications: a practical guide. compend contin educ Dent.1997;18:1013-1036

23. labanca m, leonida a, rodella fl natural or synthetic biomaterials in Dentistry: science and ethic ascriteria for their use. implantologia 2008; 1:9-23

24. metsger D.s. et al. (1982). tricalcium phosphate ceramic--a resorbable bone implant: review and currentstatus. J am Dent assoc.105: 1035-1038.

25. Jensen ss, broggini n, Hjorting-Hansen e, schenk r, buser D. bone healing and graft resorption ofautograft, anorganic bovine bone and beta-tricalcium phosphate. a histologic and histomorphometricstudy in the mandibles of minipigs. clin oral implants res 2006; 17:237–243.

26. artzi Z, Weinreb m, givol n, et al. biomaterial resorption rate and healing site morphology of inorganicbovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study andmorphometric analysis. int J oral maxillofac implants 2004;19:357–368.

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3. R.T.R. TECHNICAL SPECIFICATIONS

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R.T.R. Properties: R.T.R. features specific structural properties that foster osteogenic cell colonization.

COMPOSITION: Synthetic ß-tricalcium phosphate granules (ß-TCP) PARTICLE SIZE: From 500 μm to 1 mm MACROPORES: From 100 μm to 400 μm MICROPORES: < 10 μm RESORPTION: 3 to 6 months (depending on the patient’s physiology)

R.T.R. Indications: R.T.R. is indicated in most clinical cases requiring oral bone replacement:

Post extraction socket grafting (post-extraction ridge preservation) Ridge augmentations Periodontal defects Peri-implant defects Sinus lift Defects following apical endodontic surgery

R.T.R. Characteristics:

Synthetic ß-TCP granules Resorbable with new bone formation Micro and macroporous Maximises alloplast colonization by osteogenic cells for bone augmentation

Hydrophilic material Drawn into the surgical site and provides easy contouringwhen filling bony voids

High level of purity + sterilization Biocompatibility and safety

Available in 3 presentations Suits main clinical indications

R.T.R. Cone: addition of highlypurified collagen* Haemostatic healing and stays in place

R.T.R. Curved Syringe 0.8 cm3 Easy direct placement thanks to a simple aspiration of patient's blood or physiological solution

R.T.R. Granules 2 cm3 High volume adapted for large defects

Double sterile packaging Meets the asepsis standards required in implantology

Features Benefits

* bovine origin

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