Phd paper plain

Mohamed Ismael As- Sa'daway Ass- lecturer Faculty of Dental Medicine Cairo (boys) Alazhar University
Dr.Akram Abass Elawady Professor of Oral Medicine, Periodontology, Diagnosis and Radiology Faculty of Dental Medicine, Cairo
(Boys)Al-Azhar University
Dr.Abdel-Fatah Mahamoud Amer Professor of Oral Medicine, Periodontology, Diagnosis and Radiology Faculty of Dental
Medicine, Cairo (Boys) Al-Azhar University
Clinical and Radiographic evaluation of marginal periimplant tissue
stability after buccal defect regeneration using porous titanium granules
Mohamed I As- Sa’daway, Akram Abass Elawady, .Abdel-Fatah Mahamoud Amer.
Abstract
Introduction and review of literature: The loss of the buccal alveolar plate is an especially challenging condition for the
clinician. Many augmentation technique have been proposed to achieve long term stability and preservation of peri implant tissue. The
stability of tissue level and contour are pre requisite for good esthetic and function, PTG has been used to enhance bone regeneration,
PTG are non-resorbable osseous replacement grafts consisting of porous, commercially pure titanium. The non-resorptive properties of
PTG may be an advantage because osseous healing and maturation clearly is a biological process very extensive in time It may thus be
beneficial to use regenerative materials that do not disappear before completion of this process. Aim of the study: The aim of this
study was to carry out clinical and radiographic evaluation of marginal periimplant tissue stability after buccal defect regeneration using
porous titanium granules. Patients and methods: Twenty patients were enrolled in the study. The age of subjects ranged from
25 -40years old, A complete examination of the oral hard and soft tissues was carried out for each patient, All implants were placed
using a standardized surgical procedure, PTG was gently condensed into the defects and around the fixtures up to the superior part of
the implant, filling out the defect The level of augmentation mimicked the original previous bone level at the installation of the fixtures.
the flaps were repositioned with nonresorbable sutures around the abutments ,Sutures were removed one (8-10) day postoperatively.
Results: Clinical measurements .gingival index and mucosal level and interdental papilla and periimplant probing depth showed
clinical stability except mucosal level and interdental papilla after four months showed statistically significant changes. Radiographic
parameter showed statistically insignificant changes all time of follow up. Conclusion Porous titanium granules (PTG) represent a
new possibility in augmenting osseous defects, particularly in those areas intended to receive dental implant.
Introduction and Review of literature: The preservation and reconstruction of bone architecture seem to be
a mandatory step for both periodontal and prosthetic treatments. Different methods have been suggested to
preserve and reconstruct adequate volume of bone and to prevent the alveolar ridge resorption following teeth
extraction. Autogenous particulate grafts ,distraction osteogenesis, and porous titanium mesh tray, or a
combination of these(1)
PTG has been used to enhance bone regeneration in a ridge splitting case of a
severely resorbed maxillary dento-alveolar ridge. The reconstruction allowed a cross arch bridge
installation. The PTG can be used for expansion of narrow bucco-lingual ridges(2). PTG are non-
resorbable osseous replacement grafts consisting of porous, commercially pure titanium. The non-
resorptive properties of PTG may be an advantage because osseous healing and maturation clearly is
a biological process very extensive in time. It may thus be beneficial to use regenerative materials
that do not disappear before completion of this process.(3) Procedures to prevent the collapse of the
alveolar ridge require different surgical designs depending upon the size of the defect.(4) Soft tissue
expansion (STE) is modality that generates excess tissue(5) of proper quantity and color without flap
transfer or residual defect is desirable during reconstruction of resorbed alveolar ridges and a variety
of bone augmentation techniques used to improve the horizontal and vertical dimensions of ridge
defects for placement of implants .When applied for lateral ridge augmentation, autogenous bone
block grafts or guided bone regeneration (GBR) techniques provide a predictable volume of
generated bone after healing.(6) On the other hand, the outcome of vertical ridge augmentation

appears less clear. Clinical and histological data support the feasibility of vertical augmentation
procedures such as onlay grafting; inlay grafting, distraction osteogenesis, or GBR(7), and the
findings are difficult to extrapolate (8). The incidence of post-operative complications varies highly
among studies, However it is apparent that soft tissue dehiscence and exposure of bone grafts to the
oral cavity are common complications of vertical ridge augmentation, comprising the outcome and
leading to partial or complete loss of the graft material in up to 40% of the cases(9).
The aim of the study: The aim of this study is the Clinical and radiographic evaluation of
marginal periimplant tissue stability after buccal defect regeneration using porous titanium
granules.
Patients and Methods: Twenty patients were enrolled in the study from those attending at
outpatient clinic in Faculty of Dental Medicine- Alazhar University. They had an edentulous area
suitable for implant placement. The age of subjects ranged from 25 -40years old. All patients were
provided with written and verbal information about the study and those who fulfilled the criteria
were invited to participate in the study, written consent had attained from all patients. Inclusion
criteria included patients with adequate bone for securing primary implant stabilization. Exclusive
criteria consisted of patients with a history of the following: Heart disease, Connective tissue
disorders, metabolic bone disease, uncontrolled diabetes and smokers.
Pre-operative work-up A complete examination of the oral hard and soft tissues was carried out
for each patient. Periapical radiographs formed the basis for the primary investigation.
Preoperative work-ups included an assessment of the edentulous ridges using casts. Cone beam
computed tomography (CBCT) scans were used as the final investigation. CBCT datasets were
acquired using a modern cone beam scanner (Kodak 9500 Carestream Health, France). The
KODAK 9500 3D System captures dual jaw (9 cm x 15 cm) or all dent maxillofacial anatomy
(18.4 cm x 20.6 cm) in one acquisition for a wide range of clinical applications. With the
additional ability to control patient dose through variable settings of mA and kV) tube voltage
60-90 kV (pulsed mode), tube current (2-15) frequency 140kh, amorphous silicon flat panel
detector, reconstruction time 2minutes and 20 seconds ,the machine Perform a three-dimensional
reconstruction of the alveolar bones. With navigation software, it was possible to correctly assess
the width of each implant site, the thickness and the density of the cortical plates and the
cancellous bone, as well as the ridge angulation.

Fig (1) patient position for CBCT
Implant placement
Implant placement was performed using a non-submerged installation procedure. The
surgical procedures were carried out under local anesthesia employing a low-trauma
surgical technique. All patients received preoperative antibiotic prophylaxis 2 hours
prior to surgery. The IHDE® dental Implants (Hexacone) - is a system for endosteal
dental implantation. All implants consist of pure titanium (Ø 4.8, 4.1 mm) or highly
break-proof titanium alloy (Ø 3.3 mm, STO®) Ti6AI4V ELI,( Ti 6Al-4V ELI is a
higher-purity "extra-low interstitial") are double sandblasted on the endosteal part and
etched in a high-temperature process, Osmoactive® packaged-were placed in
various sites. All implants were placed using a standardized surgical procedure.
A mid crestal incision was made at the sites of implant placement .The crestal
incision was connected to one or two releasing incisions or it was only limited to
envelope flap. Full-thickness flaps were reflected exposing the alveolar ridge,
and preparation of implant site was carried out with spiral drills of increasing
diameter, under constant irrigation. Implants were positioned at the bone crest
level.

Defect reconstruction
The ridge defect was classified as siebert’s class .II ,III which
described as buccal tissue loss , combination of apico-coronal and buccolingual
tissue loss .respectively figures( Standard surgical protocol was applied full
mucoperiosteal flap was elevated which included mid crestal incision involved
two adjacent teeth and one or two vertical releasing incisions the bone was
sounded and any granulation tissue was curreted , then the implant was placed
according to manufactures directions all placed implants have two or one
threads exposed or very thin buccal wall, Porous titanium granules (PTG, Natix,
Tigran AB, Sweden) were inserted in the defects and mixed with blood. The
bony walls of the defects were prepared to stimulate small bleeding points with
a small bur prior to insertion of the granules. Following the protocol supplied by
the manufacturer, PTG (particle size 700–1000µm) was gently condensed into
the defects and around the fixtures up to the superior part of the implant, filling
out the defect, The level of augmentation mimicked the original previous bone
level at the installation of the fixtures .The granules connected well together in
the clot forming a lightly moldable mass of the augmentative material, the flaps,
were repositioned with nonresorbable sutures around the abutments , Sutures
were removed one (8-10) days postoperatively .
Post-operative care: All the patients received oral antibiotics, 2 g each day for 6
days (Augmentin; Glaxo- Smithkline Beecham, Brentford, UK). Post-operative
pain was controlled by ketolac (Amriya Pharmaceutical Industries Co) every 12
h for 2 days, and detailed instructions about oral hygiene were given, mouth
rinses with 0.12% chlorhexidine (Chlorhexidine; OralB, Boston, MA, USA)
administered for 7 days. Suture removal was performed at 8–10 days. The
prosthetic rehabilitation was initiated with provionalization. Implants were
restored with a single crown, all restorations were cemented.

Fig (2) A- virtual implant placement in cbct axial view B-virtual implant placement in cbct tangential
view
C-Virtual implant placement panoramic view D- volume rendering showing implant placement
Fig (3) a- Clinical photograph showing the defect b-axial view denoting resorbed buccal plate

c- Clinical photos showing implant insertion d- permanent abutment in site
e- CBCt Axial view showing bucaccal bone f- clinical photos showing final restoration of first
premolar
Clinical evaluation: included visual inspection of the tissue color, contour and consistency.
Gingival index(10)
and probing depth, Modified Sulcus Bleeding Index,(11)
Level of the mucosal
margin(12)
,papillary presence index(13)
had been recorded., mobility , effect on the adjacent teeth ,
presences of infection, quality of life score (14)
had been measured .
Peri implant probing was used to determine the level of the mucosal margin, Peri-implant probing
depth, Effects of probing regarding bleeding exudation and suppuration.(15)
Modified Sulcus Bleeding Index: was carried out as follows; Score 0 No bleeding when a
periodontal probe is passed along the gingival margin adjacent to the implant.

Score 1 Isolated bleeding spots visible.

Score 2 Blood forms a confluent red line on margin.

Score 3 Heavy or profuse bleeding,
Papilla presence index by jemt (13)

Score 0 no papilla,

Score 1 less than half of papilla height.

Score 2 half or more of the papilla height,

Score3optimal soft tissue contour with papilla filling the entire proximal space
score,
 Score4 hyperplastic papilla

Quality of life score.
quality of life score (14)
had been measured using (OHIP-14) questionnaire that was filed in by
the patients before the clinical examination. The questionnaire formed from seven dimensions which
are functional limitation, physical pain, psychological discomfort, physical disability, psychological
disability, social disability and handicap. The five categories of response for each item are never (= 0),
hardly ever (= 1), occasionally (= 2), fairly often (= 3) and very often (= 4). Higher OHIP scores
indicate worse, and Lower OHIP scores indicate better oral health-related quality of life.
A = Functional limitation (’trouble pronouncing words because of problems with teeth, mouth or
dentures’ (OHIP 1) and ’sense of taste has worsened because of problems with teeth, mouth or
dentures’ (OHIP 2).
B = Physical pain (’painful aching in the mouth’ (OHIP 3) and ’uncomfortable to eat any foods
because of problems with teeth, mouth or dentures’ (OHIP 4).
C = Psychological discomfort (’have been self-conscious because of teeth, mouth or dentures’ (OHIP
5) and ’have felt tense because of problems with teeth, mouth or dentures’ (OHIP 6).
D = Physical disability (’diet has been unsatisfactory because of problems with teeth, mouth or
dentures’ (OHIP 7) and ’have had to interrupt meals because of problems with teeth, mouth or
dentures’ (OHIP 8).
E = Psychological disability (’difficult to relax because of problems with teeth, mouth or dentures’
(OHIP 9) and ’have been a bit embarrassed because of problems with teeth, mouth or dentures’ (OHIP
10).
F = Social disability (’have been a bit irritable with other people because of problems with teeth,
mouth or dentures’ (OHIP 11) and ’have had difficulty doing usual jobs because of problems with
teeth, mouth or dentures’ (OHIP 12).
G = Handicap (’have felt that life in general is less satisfying because of problems with teeth, mouth
or dentures’ (OHIP 13) and ’have been totally unable to function because of problems with teeth,
mouth or dentures’ (OHIP 14).(16, 17)
All data were tabulated and submitted to SPSS software for staticall analysis
Radiographic assessment:
Cone beam computerized tomography (CBCT) and Prospective standard periapical
radiographic imagings have been carried out to evaluate the bone healing and crestal bone changes.
All radiographs for each case were taken under constant conditions using the RadioVisioGraphy
(RVG) direct digital intraoral radiography system (Carestream health, Verona, Roschester, USA) and
an The ORIX 70X-ray machine (ARDET Dental & Medical Devices, Milano, Italy, 70 kVpkV peak
and 8mA mean, Focal spot. 0,8 mm).
All radiographs were taken using the parallel technique and appropriate intraoral sensor
alignment instruments were obtained at 2 months base line and 4 months and at 6 months. For all
implants, the change in bone over time was measured by first marking the radiographic landmarks
(implant shoulder and two threads in the RadioVisioGraph).the image was imported to Fiji: an open-
source platform for biological-image analysis(18)
, The images were scaled and the threshold was
adjusted to the most visible conditions to determine bone level and porous titanium granules in the
RadioVisioGraph. Two horizontal line were placed one at the second implant threads and the other
line at the highest coronal level of bone , In addition two points one mesial and one distal were place
at highest level of bone proximally , This represent the most changeable area around the implant,

These radiographic input were calculated ,bone height, width, area and density were determined The
CBCT the images were 3D cropped and point registered the buccal bone was polygonally selected and
measured.
Fig (4) 3D image cropping and thresholding
I-Clinical Evaluation Results
Clinical findings showed that all implant succeeded there were no mobility, no
effect on the adjacent teeth, no infection, no intrusion in the mandibular canal,
and no bleeding
Gingival Index (GI)
The mean Gingival index (GI) was (0.7± 1.06) at the base line (two months),
(0.30± 0.48) at 4 months, and (1.20± 1.06) at 6 months following implant
placement ,There was no statistically significant difference between GI through
all periods values recorded at base line,4months and6 months Tables (1,2).
Changes in GI through the follow-up periods
Table (1): Mean, standard deviation (SD) values and results of Friedman’s test for the
changes in GI recorded at2,4 and six months following dental implant placement.
Base line 4 months 6 months
P-value
Mean SD Mean SD Mean SD
0.70 1.06 0.30 0.48 1.20 1.03 0.093
*: SignificantatP ≤ 0.05

Figure (5 ): Line chart representing changes in GI during the follow up period.
(B) Peri-implant Probing Depth (PD)
The mean probing depth (PPD) was (1. 95± 0.31) at baseline (two months), (2.03± 0.42)
at 4 months, and (1.95± 0.31) at 6 months following implant placement, There was no
statistically significant difference between PPD of the through all periods. PD is
presented in Tables (3, 4). Changes in PD through the follow-up periods
Table 2): Mean and standard deviation (SD) values and results of repeated measures ANOVA
test for the changes in PD recorded at 2,4and six months following dental implant placement.
P-value
1.95 0.31 2.03 0.42 1.95 0.31 0.791
*: Significant at P ≤ 0.05
Figure (6 ): Line chart representing changes in PD through the follow up period recorded
at 2,4and six months following dental implant placement.

(C) Level of mucosal margin
The mean mucosal level was (3.20±079) at the baseline, (2.80±1.03) at four
months, (2, 30± 0.67) at six months There was no statistically significant change in level
of mucosal margin after 4 months. From 4 months to 6 months following implant
placement, there was a statistically significant decrease in mean level of mucosal margin.
Through the whole follow-up period (Base line to 6 months), there was a statistically
significant decrease in mean level of mucosal margin Table (5, 6).
Changes in level of mucosal margin through the follow-up periods
There was no statistically significant change in level of mucosal margin after 4
months. From 4 months to 6 months, there was a statistically significant decrease in mean
level of mucosal margin. Through the whole follow-up period (Base line to 6 months),
there was a statistically significant decrease in mean level of mucosal margin.
Table (6): Mean, standard deviation (SD) values and results of Friedman’s test and
Wilcoxon signed-rank test for the changes in level of mucosal margin recorded at 2,4and
six months following dental implant placement.
P-value
3.20 a 0.79 2.80 a 1.03 2.30 b 0.67 0.004*
*: Significant at P ≤ 0.05, Different superscripts are statistically significantly
different

Figure (7 ): Line chart representing changes in level of mucosal margin through the
follow up period at 2,4and six months following dental implant placement.
(D) Papillary Presence Index
The mean of Papillary Presence Index was (3.00±0.67) at base line, (2.90±057) at
four months, (2.30±0.95) at six months; there was no statistically significant change in
Papillary Presence Index after 4 months. From 4 months to 6 months following implant
placement, there was a statistically significant decrease in mean Papillary Presence Index.
Through the whole follow-up period (Base line to 6 months), there was a statistically
significant decrease in mean Papillary Presence Index Tables (7, 8).
Changes in Papillary Presence Index through the follow-up periods
Table (8): Mean, standard deviation (SD) values and results of Friedman’s test and
Wilcoxon signed-rank test for the changes in Papillary Presence Index recorded at 2,4and
six months following dental implant placement.
P-value
3.00 a 0.67 2.90 a 0.57 2.30 b 0.95 0.032*
*: Significant at P ≤ 0.05, Different superscripts are statistically significantly
different

Figure (8 ): Line chart representing changes in Papillary Presence Index recorded at the
follow up period .recorded at 2,4and six months following dental implant placement.
(D) Quality of Life (QOL) scores
There was a statistically significant decrease in all QOL scores post-
operatively
Table (9): Mean, standard deviation (SD) values and results of Wilcoxon signed-rank test
for the changes in QOL scores
Subscale
Pre Post
P-value
Mean SD Mean SD
Functional limitation 4.05 1.23 1.50 1.15 <0.001*
Physical pain 3.80 1.47 1.65 1.18 <0.001*
Psychological discomfort 4.20 1.11 1.75 1.16 <0.001*
Physical disability 4.05 1.23 1.00 0.00 <0.001*
Psychological disability 3.75 1.37 1.05 0.22 <0.001*
Social disability 3.50 1.36 1.00 0.00 <0.001*
Handicap 3.05 1.61 1.00 0.00 0.001*
*: Significant at P ≤ 0.05

Figure (9 ): Histogram representing changes in QOL scores,recorded befor surgeryand
after final restoration. There was a statistically significant decrease in all QOL scores
post-operativel
Radiographic Evaluation Results
All radiographic parameters bone width ,hight,areand denisty measured in
periapical,and cone beam ct at base line a(two months and four months and six months
after implant placement showed stastisitically insgnificant changes table

Mean ±SD and Range of bone width,hight,area and denisty values obtained from
periapica l and CBCT radiogrph, no signficant changes all the time of follow up
Discussion
The stability of periimplant bone and enhanced osseointegration can be viewed in respect
to the formation of an inert titanium oxide layer this was proved, as thick as about 2000 µm
was found on the implant surface 6 years after implantation. Analysis of this newly formed
layer revealed that it contains organics and inorganics (Ca, P, S), indicating that the oxide
layer on implant surface is very sensitive to the intake and rise of these mineral ions and
can respond to them, even though it is coated by a layer of protein. Moreover, exposure of
the pure titanium
or titanium alloy surface to the blood led to spontaneous formation of titanium phosphate
and calcified compound containing hydroxyl groups on oxide layer plasma had happened.
Additionally calcium phosphate deposition on pure titanium surface in case of low pH at
the implant area can be accelerated. Therefore, the oxide layer is a dynamic system which
plays a role in bone remodeling and forms a compatible interface between implant and
bone. The interface may even spread to neighboring areas.(19) Integration process of
titanium granules and new bone induced a microenvironment in advance fitting for
integration of titanium and bone. In the later implantation, the local environment will be

more appropriate to osseointegration, and promoting osseointegration at microenvironment
level, leading to increasing success rate of implantation. The characteristics of inorganic
materials that undergo surface modifications on its own surface, or so-called physiologic
camouflage, to adapt to the need of body, are very rare in other inorganic materials. The
application of titanium as graft material not only involves bone mass but also induces
osseointegration from the essence of bone and titanium integration, thus allowing the new
generated bone more adapted to osseointegration(20). The papilla level around anterior
single-tooth implants influenced by multiple factors including the peri-implant biotype,
mucosal level, the implant fixture angle, the interproximal bone crest level, the depth of
implant platform, and the level of first bone to implant contact. Adequate bone volume is
essential for esthetic outcomes, in the present study the bone changes along the follow up
period was statistically insignificant but the papilla index and mucosal level showed after
four months significant changes .After four months the facial mucosal levels changes were
significant which was coincident with the increase in gingival index; this may be due to
soft tissue remodeling(21) The scope of the different study methodology approaches implies
the difficulties of understanding the complexity of biological factors that contributes to the
role in the development of the interproximal papilla (202,). Similar findings in another study
revealed that a mean loss of 0.4 mm in vertical height of soft tissue from baseline to 6
months after augmentation(22) . It was statistically significant However, in the absence of
augmentation, has demonstrated 0.9 mm of soft tissue collapse which is much greater,
augmentation reduced the soft tissue collapse considerably but was not able to prevent it
completely (37). When the baseline soft tissue width was compared with 6 months post-
augmentation soft tissue width, a mean gain of 0.4 mm was observed.(23)
It could be concluded that:
Porous titanium granules (PTG) represent a new possibility in augmenting
osseous defects, particularly in those areas intended to receive dental implant.
The stability of bone following porous titanium augmentation was higher than
that of the soft tissue, which requires further clarification.
It could be reasonable to recommend the use of additional biomodifier for
enhancement of soft tissue integrations to obtain, hopefully, better results of
both hard and soft tissues that will aid toward better tissue stability and
successful dental implant.
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