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 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

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 thresholdingI-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 monthsP-value

Mean SD Mean SD Mean SD

0.70 1.06 0.30 0.48 1.20 1.03 0.093

*: Significant at P ≤ 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.

Base line 4 months 6 monthsP-value

Mean SD Mean SD Mean SD

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.

Base line 4 months 6 months

P-value

Mean SD Mean SD Mean SD

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 periodsTable (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.

Base line 4 months 6 monthsP-value

Mean SD Mean SD Mean SD

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

SubscalePre Post

P-valueMean 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 titaniumor 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 augmentingosseous 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 forenhancement of soft tissue integrations to obtain, hopefully, better results ofboth hard and soft tissues that will aid toward better tissue stability andsuccessful dental implant.

1. Thor A. Reconstruction of the anterior maxilla with platelet gel, autogenous bone, and titanium mesh: a case report. Clin Implant Dent Relat Res. 2002;4(3):150-5.2. Holmberg L., Forsgren L., Kristerson L. Porous titanium granules for implant stability and bone regeneration – a case followed for 12 years. Ups J Med Sci 2008;113:217–20.3. Wohlfahrt J.., Monjo M., Ronold H. Aass A. Ellingsen J., Lyngstadaas S.P. Porous titanium granules promote bone healing and growth in rabbit tibia peri-implant osseous defects. Clin Oral Implants Res. 2010;21(2):165-73.4. Langer B., Calagna L. The subepithelial connective tissue graft. J Prosthet Dent. 1980;44(4):363-7.5. Bahat O., Fontanessi R.. Implant placement in three-dimensional grafts in the anterior jaw. Int J Periodontics Restorative Dent. 2001;21(4):357-65.6. McAllister B.., Haghighat K. Bone augmentation techniques. J Periodontol. 2007;78(3):377-96.7. Esposito M., Grusovin M.., Felice P., Karatzopoulos G., Worthington H.V., Coulthard P. Interventions for replacing missing teeth: horizontal and vertical bone augmentation techniques for dental implant treatment. Cochrane Database Syst Rev. 2009(4):CD003607.8. Kaner D., Friedmann A. Soft tissue expansion with self-filling osmotic tissue expanders before vertical ridge augmentation: a proof of principle study. J Clin Periodontol. 2011;38(1):95-101.9. Urban I., Jovanovic S., Lozada J.. Vertical ridge augmentation using guided bone regeneration (GBR) in three clinical scenarios prior to implant placement: a retrospective study of 35 patients 12 to 72 months after loading. Int J Oral Maxillofac Implants. 2009;24(3):502-10.10. Loe H., Silness J. Periodontal Disease in Pregnancy. I. Prevalence and Severity. Acta Odontol Scand. 1963;21:533-51.11. Mombelli A., van Oosten M.., Schürch E., Lang N. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol. 1987;2(4):145-51.12. Narula S., Garg D., Pamecha S., Asopa V. Clinical evaluation and diagnostic parameters for monitoring the prognosis of implants. Journal of Advanced Oral Research. 2012;3(1).13. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent. 1997;17(4):326-33.14. Parkerson J., Broadhead W.., Tse C. Quality of life and functional health of primary care patients. Journal of Clinical Epidemiology. 1992;45(11):1303-13.15. Bragger U., Burgin W.., Hammerle C.., Lang N. Associations between clinical parameters assessed around implants and teeth. Clin Oral Implants Res. 1997;8(5):412-21.16. Slade G.. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol. 1997;25(4):284-90.17. Strassburger C., Heydecke G., Kerschbaum T. Influence of prosthetic and implant therapy on satisfaction and quality of life: a systematic literature review. Part 1--Characteristics of the studies. Int J Prosthodont. 2004;17(1):83-93.18. Schneider C.., Rasband W.., Eliceiri K.. NIH Image to ImageJ: 25 years of image analysis. Nat Meth. 2012;9(7):671-5.19. Sabetrasekh R., Tiainen H., Lyngstadaas S., Reseland J., Haugen H. A novel ultra-porous titanium dioxide ceramic with excellent biocompatibility. J Biomater Appl. 2011;25(6):559-80.20. Wu Y., Yang Y., Zhou Y., Gu Y., Fu X. A new view on bone graft in dental implantation: Autogenous bone mixed with titanium granules. Dental Hypotheses. 2013;4(1):13.21. Kolte A.., Kolte R.A., Mishra P.R. Dimensional influence of interproximal areas on existence of interdental papillae. J Periodontol. 2014;85(6):795-801.22. Gupta S., Deo V., Williams C. Interproximal Papillae Reconstruction around Implant Using Subepithelial Connective Tissue Graft in Maxillary Anterior Region: A Case Series. J Oral Maxillofac Res. 2012;3(2):e1.

23. Desai A., Thomas R., Shah R., Mehta D. Immediate 3-dimensional ridge augmentation after extraction of periodontally hopeless tooth using chinblock graft. J Clin Exp Dent. 2015;7(5):e576-83.