BIOINTEGRATION OF BONE GRAFTING MATERIALS AND

OSSEOINTEGRATED IMPLANTS IN ORAL AND MAXILLOFACIAL

SURGERY

Semmelweis University PhD School Thesis

Dr. Umberto Garagiola

Dental and Stomatologic Clinic
Department Oral Surgery
University of Milan – Italy

Clinical Medical Sciences Dental Research

Head of the School Head of the programme
Prof. Dr. Zsolt Tulassy Prof. Dr. Árpád Fazekas

Supervisor
Prof. Dr. György Szabó

Semmelweis University
Department of Oral and Maxillofacial Surgery, Budapest
Head Dr. József Barabás

Budapest 2006

1
CONTENTS

List of abbreviation pag. 3

1. Introduction pag. 4
2. Aim pag. 10
3. Osseointegration in implant dentistry pag. 11
3.1 Sinus Elevation pag. 15
3.2 Ectodermal Dysplasia pag. 18
4. Bone grafts and substitutes: materials pag. 21
4.1 Autogenous and allogeneic bone pag. 21
4.2 Synthetic bone substrates materials: alloplastic grafts pag. 27
4.3 Xenogeneic bone material pag. 29
5. Bone grafts and substitutes: mechanism pag. 33
5.1 Bone conduction pag. 33
5.2 Bone induction (protein-BMP) pag. 34
5.3 Guided tissue regeneration pag. 35
6. Material and methods pag. 38
6.1 Material and methods: Sinus elevation pag. 38
6.2 Material and methods: Ectoderma Dysplasia pag. 41
7. Results pag. 44
7.1 Results: Sinus elevation pag. 44
7.2 Results: Ectodermal Dysplasia pag. 51
8. Discussion pag. 53
8.1 Discussion: Sinus elevation pag. 53
8.2 Discussion: Ectodermal Dysplasia pag. 57
9. Conclusions pag. 60
10. Summary pag. 61
11. Bibliography pag. 63
12. List of Author’s publications pag. 83
12.1 List publications connected with the topic pag. 83
12.2 List publications non connected with the topic pag. 86
13. List of Author’s abstracts pag. 89

2
13.1 List of abstracts connected with the topic pag. 89
13.2 List of abstracts non connected with the topic pag. 109
14. Acknowledgements pag. 125

3
LIST OF ABBREVIATIONS

Guided Bone Regeneration GBR

Scanning Electron Microscopic SEM
Transmission Electron Microscopic TEM
Titanium Plasma-Sprayed TPS
Hydroxyapatite HA
Bovine Spongiform Encephalopathy BSE
Particulate Marrow Bone Cancellous PMBC
Tricalcium Phosphate TCP
Recombinant Human Bone Morphogenetic Protein rh-BMP
Deoxyribonucleic Acid DNA
Hard Tissue Replacement HTR
Polyhydroxyethyl Methacrylate PHEMA
Computerized Tomography CT
Ectodermal Dysplasia ED
Expanded Polytetrafluoroethylene e-PTFE
Probing Depth PD
Modified Plaque Index mPLI
Modified Sulcus Bleeding Index mSBI
Tricalcium Phosphate Granule CG
Osteogenic Mesenchyme OM
Bone Graft BG
Anorganic Bovine Bone ABB

4
1. - INTRODUCTION

The reconstruction of large skeletal deficiencies presents a challenging problem

to the oral and maxillofacial surgeon and surgical community. Such defects in the facial
skeleton can be the result of trauma, infection, congenital defects, cranio-facial
syndromes, severe periodontitis, or tumor resection. In the reconstructive process there
is often a need to create new bone.
A solely prosthetic approach to management of alveolar bone loss frequently
leads to esthetic and/or functional compromises. Today, specific surgical techniques
extend implant options and optimize their final results:
- extraction and immediate implant placement
- tuberosity and pterygomaxillary implants
- partial intrasinus and nasal fossa implants
- sinus grafting
- onlay bone grafts
- dental nerve repositioning
- guided bone regeneration (GBR)
- osteotomies and bone grafts
- tissue engineering procedures
- alveolar distraction osteogenesis
A main hindrance for successful bone healing and for creation of new bone is
the rapid formation of the soft connective tissue. Ingrowth of soft tissue may disturb or
totally prevent osteogenesis in a defect or a wound area. The mechanisms behind the
influence of soft connective tissue on osteogenesis are not yet fully understood.
Experiments in vitro have demonstrated that fibroblasts produce one or more soluble
factors that are inhibitory to bone cell differentiation and osteogenesis.1 Another
possible explanation suggested by Schmitz et al2 is that a bony non-union development
may be due to the failure of the cells that are present to calcify the matrix, perhaps
caused by the lack of appropriate bone derived growth and differentiation factors in
large bony defects. Another frequently occurring clinical situation that causes
significant problems for reconstruction is the atrophic edentulous jaw, since the
introduction of reliable oral implant techniques, partially or totally edentulous patients

5
can be successfully treated with jawbone-anchored prostheses. However, a prerequisite
for the use of oral implants is a sufficient amount of bone to fully cover the implant and
to allow the implant to support a fixed prosthetic restoration. Even a minor lack of bone,
either horizontal or vertical, may cause a significant problem. A narrow or buccally
concave alveolar ridge may result in exposed threads at the alveolar crest or at bone
fenestrations. Anatomic restrictions, such as the nasal cavity, maxillary sinuses, and
inferior alveolar nerve, in combination with insufficient amounts of bone may dictate a
less advantageous placement of the implants, compromising the final restorative result.
Numerous methods have been used in an attempt to solve this problem. One of the most
common methods involves the harvesting and implantation of fresh autogenous bone
grafts.3 (Figures 1., 2., 3., 4.)

Fig. 1. A narrow alveolar ridge Fig. 2. Bilateral harvest from mental symphisis

Fig. 3. Autogenous grafts fixed by mini screws Fig. 4. After reconstruction of bone defect,
and covered by anorganic bovine bone optimal for implant insertion

6
 However, this is an expensive procedure that requires hospitalization as well as
the potential risk for donor site morbidity. Even though similar methods have been used
in more advanced situations of oral reconstructive therapy, only limited scientific data
exist regarding the long-term outcome of such treatment. Other methods use bone
powder implants or various commercially available allografts. Most of these materials
act as passive scaffolds, and it is questionable whether such techniques have any real
inductive effects on osteogenesis at the cellular level.
In recent years, much research has been focused on the osteogenic potential of
demineralised bone powder implants. The stimulatory effects appear to be due to local
morphogenic factors inherent in the implanted bone matrix. In general the technique has
shown good experimental results,4 but more research is necessary before it can be
applied routinely in patients.
Thus, whereas many different methods to improve bone healing and regenerative
capacity have been tested, with varying degrees of success, few have reached the stage
of routine clinical application. While the future holds promise for new ideas in this area,
it is tempered by the realization that the restoration of a deficient skeleton by natural
bone remains the ultimate goal.5
Autogenous graft or allogeneic graft? For many years, the reconstruction of bone
defects has been achieved using a variety of bone substitute materials. The question of
the “best” graft material has been addressed intensively by researchers, and as a result, a
large number of experimental and clinical publications have appeared on this topic.6-19
In 1996, a Consensus Conference on sinus grafting made an attempt to summarize and
evaluate the research findings.20
One of the most important conclusions of the conference was that retrospective analyses
did not reveal any bone substitute material that was equivalent to autogenous spongiosa.
Accordingly, “…many participants believed that autografts were the most
efficacious…” and “the doubts raised revealed the need for controlled prospective
multicenter clinical trials”.
In essence, the question lies in how to avoid morbidity at bone graft donor sites.21,22 It is
increasingly clear that, in addition to basic animal experiments, there is a need for
clinical investigations that apply the gold standard principle to compare autogenous
bone and various bone substitute materials. (Figures 5., 6., 7.)

7
Fig. 5. Bone window of lateral sinus wall Fig. 6. Elevated sinus membrane and bone
with inserted implants

Fig. 7. Sinus filled by bone graft

An important publication in this respect is that of Groeneveld and coworkers.23

They compared 4 materials: osteogenic protein 1 (on a collagen carrier), human freeze-
dried demineralized bone matrix, autogenous bone, and nongrafted alveolar crest. In a
total of 12 patients (3 for each of the materials), histologic and histomorphometric
methods were used to detect new bone formation during sinus floor elevation and
implantation. All grafted sinuses exhibited an increased proportion of osteoid, as
compared with nongrafted sinuses. It was concluded that in human sinus floor elevation,
osteogenic protein has a potential bone-inductive capacity; however, the results with
this material were inconsistent.
Yildirim and associated24 used a combination of Anorganic Bovine Bone (ABB) and
venous blood as a graft material. Six months after sinus floor augmentation, they found
14.7% new bone, 29.7% ABB, and 55.6% soft tissue in the tissue samples (soft

8
tissue=blood vessels and connective tissue composed of various proportions of
fibroblasts and collagenous fibres). It is interesting to compare these results with the
data reported in 1991 by Schenk,25 who found that the bone content of the human iliac
crest was 20% to 25%, depending on age. Naturally, one of the problems to be
considered in this regard is the extent to which Anorganic Bovine Bone (ABB) is
resorbed.
In the literature, the resorption of bovine bone substitute materials has been the subject
of controversy. Schlegel and Donath26,27 were able to identify the presence of ABB
granules even after a resting time of up to 7 years. It was demonstrated histologically by
Skoglund and colleagues 28 that ABB particles could be found in the maxilla 44 months
after implantation. Some publications based on animal experiments have furnished
histologic evidence of the resorption of ABB.24,29-31
An example of control is provided by the paper by Tadjoedin and coworkers.32 Bilateral
sinus grafting was performed on 10 patients; 1:1 mixture of autogenous bone particles
and bioactive glass particles was used on the experimental side, and autogenous bone
alone was used on the control side. At 6 months, bone tissue on the experimental side
had increased to 32%, differing only slightly from the control side, which contained
38% bone by volume. At 16 months, the total bone volume on the experimental side
was similar to that on the control side. After 16 months, the quality and density of bone
in the augmented sinus floor were similar, regardless of whether or not bone particles or
a mixture of bone particles and bioactive glass particles had been applied.
In addition to histology and histomorphometry,33-38 modern imaging procedures39-47 are
being applied more frequently for sinus graft examination. At the Sinus Consensus
Conference,20 panoramic radiographs appeared logical for the comparison of a large
number of patients. Long-term results of sinus grafting may be monitored by a number
of known computer tomographic methods, but these have seen limited use. Kent,40 for
example, examined bone levels from the new sinus floor to the alveolar crest and the
apex of the implant. Alveolar bone height was considered satisfactory if the new bone
exceeded the apex of the implant by at least 2 mm even after 5 to 10 years.
These data and the Consensus Conference20 have raised the question (among others) of
how the immediate and long-term success of planned sinus grafting can be monitored,
not only histologically, as with delayed implant placement, but also more accurately.

9
The significance of pure-phase β-tricalcium phosphate as a bone substitute material has
increased in recent years. It has been used in maxillofacial preprosthetic surgery,
implant dentistry, traumatology, orthopedics, and hand surgery.48-55 The treatment
modes in maxillofacial surgery have included the filling of large cysts, sinus grafting,
augmentation, and the filling of periodontal lesions. It has been demonstrated that β-
tricalcium phosphate is fully resorbed in 12 to 18 months and is replaced by bone that is
similar both functionally and anatomically to the original bone. In view of these
favourable properties, some Authors sought to determine whether this bone substitute
alone is an appropriate sinus graft material and whether it is suitable for the filling of
large bone cysts.55 Accordingly, prospective controlled studies were planned in selected
patients.

10
2. – AIM

The purpose of this work is to show the role of the implant osseointegration
associated to bone regeneration and to the reconstruction of large skeletal defects used
in oral and maxillofacial surgery, for restoring function and esthetics in edentulous
patients. The resorbed ridge may compromise loading and function of the implants
because of off-axis loading, compromising the predictability of implant therapy.
Ridge augmentation and sinus elevation procedures are now being employed to regain
lost alveolar structures. These surgical procedures include the use of autogenous,
allogeneic and xenogeneic bone grafts, synthetic bone substitutes, and non-resorbable or
resorbable barrier membranes as described in the guided bone regeneration (GBR)
principle. So they have expanded the treatment modality for patients whose ridges are
not ideal for implant placement.
The preferred bone graft material during a bone reconstructive procedure, as in ridge
augmentation and sinus elevation, is autogenous bone, as it carries proteines such as
bone-enhancing substrates, minerals and vital bone cells, but this often needs
hospitalization, other surgical operations and it has a potential risk for donor site
morbidity.
Two different studies have been performed.
1. The objective of the former was to determine whether during sinus elevation the
donor site morbidity could be avoided by using pure-phase β-tricalcium phosphate.
2. The objective of the latter was to verify if it is possible to achieve an optimal bone
reconstruction through osseointegrated implants, bone grafts and guided bone
regeneration also in patients affected by severe orofacial syndromes as Ectodermal
Dysplasia.

11
3. – OSSEOINTEGRATION IN IMPLANT DENTISTRY

Based on fundamental experimental studies performed by the research teams of P.-I.

Brånemark from the University of Göteborg, Sweden, and A. Schroeder from the
University of Berne, Switzerland, the use of dental implants has become a scientifically
accepted treatment concept in dentistry to replace lost or missing teeth in fully and
partially endentulous patients. This breakthrough in implant dentistry was initiated by
the discovery that dental implants made of commercially pure titanium can be anchored
in the jawbone with direct bone contact. In a landmark paper published in 1969,
Brånemark et al56 described this phenomenon for submerged titanium implants from a
clinical point of view and with decalcified histologic sections (the implants had to be
removed before sectioning).
Seven years later, Schroeder et al57 provided the first true histologic evidence of direct
bone-to-implant contact for nonsubmerged titanium implants using nondecalcified
histologic sections with the titanium implant still present in the specimens. Later, these
authors created the terms osseointegration and functional ankylosis58 to describe this
phenomenon. In the past 10 years, the terms osseointegration and osseointegrated
implants have been widely used in the literature.
An osseointegrated implant is characterized in light microscopic analysis by a direct
apposition of bone to the titanium surface without evidence of a separating connective
tissue layer between the bone and the implant. Hereby, the bone has all characteristics
of living bone, such as osteocytes or blood vessels, close to the implant surface. (Figure
8.)

Fig. 8. Osseointegrated implant

12
Osseointegration has also been documented in scanning electron microscopic (SEM)
studies58 as well as in a transmission electron microscopic (TEM) study.59
To achieve an osseointegrated titanium implant with high predictability, the implant
must be inserted with a low-trauma surgical technique, avoiding overheating of the bone
during preparation of a precise recipient site; must be placed with initial stability; and
should not be functionally loaded during the healing period of 3 to 6 months. When
these clinical guidelines are followed, successful osseointegration will occur predictably
for nonsubmerged titanium implants (one-stage procedure) as well as for submerged
titanium implants (two-stage procedure), as has been demonstrated in comparative
experimental studies.60
The best-documented two-stage implant system is the Brånemark System, whereas the
most prominent one-stage system using nonsubmerged titanium implants with a
titanium plasma-sprayed (TPS) surface is the ITI System. The basic characteristics,
indications, and clinical procedures of both implant systems have been described in
detail in textbooks written by Brånemark et al.61
In addition to demands from patients for high reliability and optimal esthetics, it is
desirable to shorten the treatment period for economic and social reasons. One way of
reducing the treatment period is to use 1-stage surgery and non-submerged implants.62,63
Another way of reducing the treatment period is to shorten the time between implant
insertion and the placement of a prosthetic suprastructure on the implants.
During the healing period, in cases of complete or partial edentulism, the patient usually
wears some sort of removable prosthesis. Normally, the patient has to refrain from
wearing the removable prosthesis during the first 2 weeks after implant placement and
thereafter must wear it during the entire healing period of about 3 to 6 months. In recent
studies, the problems of unfavourable loading caused by removable prostheses after 1-
stage surgery have been discussed.64-66
The idea has arisen that the prostheses cause the implants exposed through the mucosa
to undergo micromotion, leading to crater-shaped marginal bone defects. One possible
way to minimize micromotion is to enhance the stability of the implants by splinting the
implants with a provisional, screw-retained, implant supported prosthesis in a fixed
position immediately after surgery.67 A prerequisite for such an immediate technique is

13
1-stage surgery with non-submerged implants. Few studies have been published on the
effects of immediate loading of implants. In the mandible, success rates similar to those
68
with healing times of 3 to 6 months before loading have been reported. Studies on
immediate loading of maxillary implants are scarce, but the results reported indicate that
this method is also viable.67,69-71 The scientific documentation, however, is poor.72-73
Bergkvist et al64 indicated that immediate splinting of the implants with a fixed
provisional prosthesis might protect non-submerged implants from unfavourable and
uncontrolled loading and improve the healing conditions. Immediately loaded ITI SLA
solid-screw dental implants supporting fixed prostheses in the edentulous maxilla can be
a viable treatment alternative when restoring the edentulous maxilla.
The long-term documentation of osseointegrated implants was first reported by Adell et
al74 in a retrospective clinical study treating fully edentulous patients with Brånemark
implants. The authors reported estimated implant survival rates of 86% in the mandible
and 78% in the maxilla at 15 years.74 Data published from prospective studies on fully
edentulous patients by Zarb et al75 have confirmed these results. Similar results of
retrospective studies have also been reported for nonsubmerged ITI implants placed in
fully edentulous patients by Babbush et al,76 Bruggenkate et al,77 and Krekeler et al.78
In the mid-1980s, clinical investigators started to focus more on the treatment of
partially edentulous patients in order to expand indications for osseointegrated implants.
Although related 10 year data are still lacking for any implant system, encouraging
results with ITI implants were found in a prospective study on partially edentulous
patients at the University of Berne. Applying strict criteria for success, the examination
up to 5 years demonstrated success rates above 95%. Mean success rates above 90%
have also been reported for Brånemark implants in a prospective study by Zarb and
Schmitt.79,80 5-year results with success rates above 90% applying life table analysis,
have also been presented for the IMZ system (Interpore International, Irvine, CA) for
fully and partially edentulous patients.
Encouraging treatment results of patients with standard indications have, in the past 5 to
10 years, led to increasing interest in the use of dental implants in “borderline”
indications, such as recipient sites with insufficient bone volume, recipient sites close to
specific anatomic structures (mandibular nerve, maxillary sinus, etc), extraction sockets,
and esthetically demanding sites.

14
 One of the most important prerequisites to achieve the above mentioned success
rates with any kind of osseointegrated implants is the presence of a sufficient amount of
healthy jawbone at the recipient site. This does not only include an adequate bone
height, but also a sufficient crest width. Clinical studies have clearly demonstrated that
the success rate of Brånemark implants is compromised in areas of poor bone quality or
on those with good quality but inadequate bone height. Screw-type implants with a
larger, 5-mm diameter have been recommended for that special situations.81 An
alternative solution for this problem is the use of titanium implants with a rough
titanium surface in the bone-anchoring section, such as the TPS surface. Experimental
studies have indicated that the anchorage of titanium implants with a TPS surface is
significantly improved when compared with polished or fine-structured surfaces. Thus,
titanium implants with a TPS surface, have also been successfully utilized in recipient
sites with poor bone quality or reduced vertical bone height. In addition, titanium
implants with a hydroxyapatite (HA) coating have been recommended for these
indications, because the HA coating accelerates bone apposition to the implant surface
in the early healing period and significantly improves the anchorage in bone.82
However, several publications have reported that the HA coating is biologically
unstable over time and shows signs of resorption in histologic studies. This observation
might be a contributing factor for the increased rate of complications 3 to 5 years after
implant placement, such as severe bone defects around failing or failed HA implants.
New surgical techniques have recently been developed to allow the placement of dental
implants in areas with extremely reduced vertical bone height. One of these techniques
is the simultaneous use of dental implants with autogenous bone grafts from the iliac
crest in severely atrophied mandibles or maxillae.83-85 In the posterior maxilla, the
vertical bone height at potential implant recipient sites is often limited by the extension
of the maxillary sinus, and the placement of endosseous implants with a standard
technique is not possible. Sinus lift procedures have been recommended to allow the
placement of implants even in sites with less than 5mm of bone height.9 In the posterior
mandible, the vertical bone height is limited by the mandibular canal with the
neurovascular bundle. To overcome this anatomic limitation, nerve lateralization has
been proposed. However, this technique is questionable for routine use in dental offices

15
and appears to be associated with an increased risk for postoperative morbidity, such as
dysfunction of the inferior alveolar nerve.85,86
A further problem is the lack of a sufficient crest width. Clinical studies have clearly
shown that the long-term prognosis of osseointegrated implants is compromised when
the buccal bone wall is missing at the time of implant placement. Various surgical
techniques have been developed to increase the width of the crest. One of the methods
uses a split technique of the narrow alveolar crest and subsequent filling of the created
gap between the two cortical bone walls with either autogenous/homologous bone grafts
or hydroxyapatite.85,87 The latest surgical technique to improve the volume of jawbone
at implant recipient sites involves the principle of guided bone regeneration (GBR).
This principle, utilizing barrier membranes, was first evaluated in the late 1950s and
early 1960s by the research teams of Bassett et al88,89 and Boyne et al90 for the healing of
cortical defects in long bones and osseous facial reconstruction. These authors utilized
microporous cellulose acetate laboratory (Millipore) filters to establish a suitable
environment for osteogenesis by excluding connective tissue cells from bone defects. In
the early 1980s, this principle was tested in a number of systematic experimental studies
for the regeneration of lost periodontal tissues. In implant dentistry, such membranes
have been clinically tested in various indications.91-95

3.1 - SINUS ELEVATION

Sinus elevation (sinus lifting, sinus grafting) has become one of the most
commonly performed routine surgical procedures in preprosthetic surgery. The essence
is that the alveolar process of the atrophic maxilla is made thicker towards the maxillary
sinus, and made suitable to receive the implant.
The surgical procedure is a standard aseptic procedure, carried out under local or
general anaesthesia. The sinus augmentation procedure was described by Boyne and
James: For grafting of the maxillary sinus floor with autogenous marrow and bone, a
supracrestal incision is made from the canine or first premolar area and extended
posteriorly to the ipsilateral maxillary tuberosity region. Vertical releasing incisions
may be made in the canine and tuberosity region. A mucoperiosteal flap is raised to
expose the lateral wall of the sinus. A rectangular osteotomy is outlined with a round
burr, ensuring that the inferior osteotomy is outlined with a burr, ensuring that the

16
inferior osteotomy is about 5 mm above the sinus floor. The osteotomy is completed
with hand instrumentation. The superior osteotomy is left intact to allow infracture of
the lateral sinus wall. The sinus membrane is carefully elevated within the sinus cavity
so that it is completely free inferiorly, anteriorly, posteriorly and medially.
Simultaneously, the lateral sinus wall is fractured inwardly. A portion of the antral
space is filled with the graft material or autogenous cancellous bone.
The bone graft or/and bone-substituting material is placed in this cavity. A
number of donor sites come into consideration, like the mental region, the maxillary
tuber, etc. The enossal implantation may be performed at the same time; for undisturbed
healing, at least 5 mm thickness of the sinus floor is necessary in order to ensure
appropriate primary stability for the implants. (Figure 9.)
The mucoperiosteal flap is repositioned and sutured.

9a

9b

17
9c

9d

9e

Fig. 9. a-e Outline of sinus grafting: A bone window is formed in the facial wall of the maxillary
sinus; this is broken in, but maintaining the integrity of the sinus mucosa the maxillary sinus is
filled. If there is primary stability, implant is inserted

18
3.2 – ECTODERMAL DYSPLASIA

Ectodermal dysplasias (EDs) are a large, heterogeneous group of inherited

disorders that involve primary defects in the development of two or more tissues
derived from ectoderm. (Figure10.)

a b
Fig. 10. (a) X-linked hypohidrotic Ectodermal Dysplasia: localization within the region Xq11-
q21.1.
(b) Tissues derived from Ectoderm.

These tissues include the hair, teeth, nails, skin, secretory glands (sweat, eccrine,
tear, and salivary glands), and mucous glands in the throat, larynx, respiratory system,
and intestinal tract.
The typical dysmorphic facial features include frontal bossing, malar hypoplasia, a
flattened nasal bridge or saddle nose, prominent supraorbital ridges, wrinkled,
hyperpigmented periorbital skin, thick, everted lips, and prominent low-set ears (Figure
11.).

19
 Fig. 11. Typical facial features of Ectodermal Dysplasia (ED).

The dental findings range from complete anodontia to hypodontia of the primary
or permanent teeth, widely spaced, peg-shaped, or conical teeth, delayed eruption, and
defective enamel of the permanent teeth. (Figures 12., 13.)

Figs. 12-13 Intraoral and radiographic aspects: hypodontia and dental anomalies.

When teeth are missing, the jawbone alveolar processes do not develop properly,
so the skeletal vertical dimension is reduced, resulting in protuberance of the lips. This
leads to a typical old-age appearance of the face. The palatal arch is frequently high and
a cleft lip and palate may be present.96,97 Congenital absence of the teeth is more
frequent in the lower jaw and affects the growth of the jawbones, leading to a lack of
alveolar bone in both height and width. (Figures 14., 15., 16.)

20
Figs. 14. 15. 16. Decreased edentulous alveolar bone ridge and reduced occlusal vertical dimension
by clinical and radiographic points of view.

The salivary secretion rates are reduced and the salivary glands may be absent. This
causes dryness of the mouth and an increased risk of caries. Mouth dryness can make it
difficult to soften and swallow food, and may reduce the senses of smell and taste.98,99

21
4. – BONE GRAFTS AND SUBSTITUTES: MATERIALS

The types of grafts available for the maxilla and mandible are the autogenous,
allogeneic, alloplastic, and xenogeneic.
Autogenous grafts are taken from the same person.100-102
Allogeneic grafts are composed of tissues taken from another individual of the same
species.
Alloplastic materials are synthetic substances used as substitutes for bone in grafting,
and Xenogeneic grafts are composed of tissue taken from another species (from an
animal source, usually bovine).
Characterization and analysis of any bone graft substitute prior to its use in human bone
sites involves consideration of several material properties of the graft:
1. Chemical and physiologic composition.
2. Morphologic structure.
3. Physical properties.
4. Absence of xenogeneic, allogeneic, and/or other foreign protein in the material.
Based on these properties, ideal bone substitutes should demonstrate:
1. Excellent biocompatibility, to be fully accepted by the living organism.
2. High osteoconductivity, to promote conduction of new bone formation from the
walls of the host bone defect.
3. A large inner surface area, to become fully revascularized by the host bone site.
4. High porosity, to be completely incorporated in new bone.
5. Moderately slow resorption, to remain in place, promoting long-term bone
remodelling.
6. An adequate modulus of elasticity, to guarantee a natural stress/strain
environment.

4.1 - AUTOGENOUS AND ALLOGENEIC BONE

Autogenous bone grafts (from the patient’s own body) and allogeneic (or
homologous) bankered bone (from another individual of the same species) are

22
frequently and successfully employed to promote regeneration of parts of the skeleton.
The use of these types of grafts is limited, however, by the cost of a donor site operation
for autogenous bone or by fear of the risk of infection (with human immunodeficiency
virus, hepatitis) with use of allogeneic materials.85,86,101
Autogenous grafts are usually harvested from one of the following donor sites:
1. Iliac crest (anterior superior crest or posterior superior crest)
2. Rib
3. Calvaria
4. Anterior tibia
5. Intraoral sites
6. Free flaps (fibula with microvascular anastomosis)
The principal harvesting sources of bone grafting materials are selected primarily to
provide the maximal amount of particulate marrow and cancellous bone (PMCB) to
deliver the highest potential number of pluripotential or osteogenic precursor cells in the
graft material mass. These cells are used in effecting the restoration of the deficient
bone area. Although some pluripotential cells exist in the host bone wall, depending on
the type of defect involved, delivery of a graft of high osteogenetic material with a great
number of these preosteoblastic cells and pluripotential cells102,103,104 tends to increase
the potential for success and enhance the quality of the final restorative result.
Therefore, most of the donor sites used for autogenous bone grafting provide a basis for
obtaining an optimally high amount of PMCB.

The iliac crest graft is considered to be the gold standard of graft materials
because of the high population of pluripotential cells in the particulate cancellous bone
and marrow portion of the graft. These cells are available for introduction to become
osteoblasts and to form new bone. These pluripotential cells are located primarily in the
vascular marrow spaces of the cancellous bone (PMCB).85,105
The principal complications of taking bone from the posterior iliac crest are adynamic
ileus and hernia. However, in reviewing more than 170 cases involving posterior iliac
crest harvesting performed over 18 years, some Authors have not observed a single case
of ileus or bowel hernia1.

23
Harvesting of the anterior iliac crest has been reported to be associated with paresthesia
of the lateral femoral cutaneous nerve1. In an experience with more than 300 anterior
iliac crest donor sites, only one patient has experienced paresthesia of the lateral femoral
cutaneous nerve. This complication occurs primarily when the incision is made too far
inferiorly on the lateral aspect of the thigh or too far anteriorly, involving an incision
immediately below the anterior iliac spine, creating an opportunity for interdiction of
the lateral femoral cutaneous nerve. Thus, the harvesting of bone from the iliac crest is,
in our experience, met with very little postoperative morbidity.
Patients are usually ambulated on the first postoperative day and released from the
hospital on the second postoperative day (sometimes even on the first day after surgery)
and are allowed to use a cane or a walker during ambulation for the first 5 days at home.
Except for not being able to climb several sets of stairs, to drive an automobile, or to
elevate the leg forcefully during the first postoperative week, patients experience very
little restriction in their range of motion or ambulation. The patient is allowed to
ambulate at will and to move slowly during the first few days postoperatively. The
principal minor complication that we have observed after this iliac crest procedure has
been formation of hematomas. When a hematoma occurs following an anterior iliac
crest procedure in which the medial table is allowed to remain intact, simple
reapplication of a pressure dressing with or without aspiration of the hematoma or
seroma suffices to treat the swelling.
If the medial table approach has been used in an anterior iliac crest harvesting procedure
and a postoperative hematoma occurs, it is very difficult to reach the involved area for
aspiration and also difficult to apply a pressure dressing in the correct direction to
effectively control the hemorrhage. Although the medial table technique is used by
many surgeons, we believe that the lateral table approach results in fewer postoperative
hematomas.
If the anterior superior iliac spine is inadvertently taken in the surgical procedure,
several complications can ensue. One of these is interference in the function of the
sartorius muscle. This affects the patient’s walking and, particularly, the patient’s ability
to lift and abduct the leg (in the manner of crossing the knees when sitting). There is
also an increased incidence of postoperative hernia when the anterior superior iliac
spine is taken. Additionally, the patient tends to experience considerable discomfort

24
during ambulation with a full-gaited walk, experiencing a delay in final rehabilitation
for a matter of 3 to 4 weeks. Therefore, we believe that the safest bone-harvesting
procedure is one in which the anterior iliac crest is harvested through the lateral
approach, leaving the medial table, the iliac crest itself, and the anterior superior iliac
spine all intact. (Figure 17.)

a b
Figs. 17. a-b Iliac crest donor site

Cranial or calvarial bone grafts are usually obtained by taking the outer table of
the calvarium with the underlying cancellous bone and marrow. The cortical bone of the
calvarial graft may be used in one piece or morselized and mixed with the cancellous
bone particles. (Figure 18. a)
One problem associated with calvarial grafts is that they are composed primarily of
cortical bone matrix. This property makes such a graft excellent for recontouring facial
bone areas. Such a graft, however, does not have the same results when applied to the
alveolar bone of the mandible and maxilla, particularly when the case involves the
reconstruction of the mandible and maxilla for root-form implants. The amount of
PMCB obtainable from cranial grafts is limited compared to the amount found in the
iliac crest. Calvarial bone grafts, when subjected to the stress of occlusal forces through
conventional prostheses or root-form, implant-bone prostheses, tend to resorb and tend
not to maintain the form and contour of the reconstructed bone area.

25
 The anterior tibial surface can be used also as a source for cancellous bone and
marrow. A moderate amount of PMCB may be obtained from the tibia and the
procedure usually results in very little morbidity. Thus, as an alternative site for
autogenous bone when approximately 30 to 40 cm3 of PMCB is needed, the anterior
tibial surface can be used preferentially after the posterior and anterior iliac crest have
been considered. (Figure 18. b) All donor sites already discussed produce PMCB graft
material that can be used in reconstructing the maxilla and mandible and for the
insertion of root-form implants. If small amounts of cancellous and marrow bone are
needed, an intraoral source may be used.

a b
Figs. 18. a-b Calvaria and anterior tibia harvests

A fibular bone transfer, when used as a free graft with microvascular

anastomosis, tends to produce a very successful soft-tissue graft transfer. However, the
osseous portion of the composite graft is composed, for the most part, of thick cortical
bone and as a result does not usually offer a high quantity of viable cells for facilitating
osseointegration with titanium root-form implant surfaces. Root-form implants placed
in such grafts require a longer period of time for integration than do similar implants
placed in PMCB grafted areas. Once implants are well integrated, however, the result
can be prosthetically satisfactory.

26
 The intraoral sites most frequently used are the mentum, which contains mostly
cortical bone; the area behind the mandibular third molar; mandibular tori, which also
contain largely cortical bone and the maxillary tuberosity. The intraoral site mostly
prefered is the retromolar area of the mandible. This site can be entered by simply using
a small, round bur to perforate the cortical bone of the anterior surface of the ascending
ramus posterior to the third molar. The small cortical bone plate is elevated to expose
the underlying cancellous bone, which is then curretted in a horizontal direction
posteriorly into the ramus. The currette is always kept in a plane parallel to the occlusal
surface of the mandibular teeth to prevent injury to the mandibular canal and the inferior
alveolar nerve. These is little chance of postoperative morbidity if care is taken
measuring from the anterior border of the ramus to the mandibular canal. The procedure
can be used bilaterally if additional graft material is needed.1,85,86
The symphysis region is an intraoral donor site of choice. The advantages of this site
versus an extraoral site are:105-111
- surgery time is shorter
- easy access
- more rapid healing
- absence of visible scars
- the postsurgical effects are well tolerated
- surgery may be performed under local anesthesia
The disadvantages of this donor of this donor site are:
- a limited quantity of bone to harvest
- risk of loss of sensitivity on the mandibular incisors
Following local and regional anesthesia (Spix’s spine), a linear incison is performed on
the mucosa between the respective distal aspects of the two canines. Reflection of a full-
thickness flap gives access to the symphysis bone. Osteotomy is performed using a bone
bur. The upper limit must be located 5 mm under the teeth apices. The depth of the bone
graft depends on the width of the symphysis and on the bony defect to be treated. The
use of osteotomes allows mobilization and harvesting of the graft. The graft is then
adapted to the recipient site. The donor site may be filled using a bone substitute or
bone hemostatic wax. The flap is repositioned and sutured using a resorbable suturing
material. (Figure 19. )

27
a b
Figs. 19. a-b Intraoral donor sites

4.2 - SYNTHETIC BONE SUBSTRATES MATERIALS: ALLOPLASTIC

GRAFTS

The use of modern bone substitutes allows regeneration to occur without scar
formation and interstitial reconstruction, in contrast with the spontaneous healing
process. The implanted materials must satisfy a number of conditions. They should not
damage the host organism, they should not contain any infective agent, and thus they
cannot transmit any type of infection. If possible, they should be fully resorbed and
should progressively be replaced by newly-formed bone tissue, these processes
proceeding synchronously. The principle of remodelling should hold, and the bone
formed should be similar to the original bone. The process of ossification should not be
slowed down, but if possible be influenced in a positive manner, by osteoconductive
means. These materials should or give rise to the formation of bone at sites where there
was originally no bone, outside the periosteum.6,53 In this work a 99% pure phase ß-
Tricalcium phosphate (beta-TCP) has been used for the regeneration of bone defects.
ß-Tricalcium phosphate exists in α and ß phases. These are identical chemically, but
under physiological conditions they behave differently. α -Tricalcium phosphate is
resorbed only very slowly, and can be detected in the new bone even years after its
implantation, whereas the ß form is fully resorbed after a few months, being replaced by

28
new bone. A certain proportion of the ß phase enters the tissues, so that phosphate ions
are present in the implanted area. The ß-TCP – ceramic phases are very stable
chemically, they are integrated into the bone without causing any reaction, on operated
site heals with scar formation and connective tissue formation. ß-TCP is fully resorbed
and replaced by new bone within a few months. It has osteoconductive effects. It is
manufactured in various grain sizes. Neither the bone-substitute material itself nor any
of its breakdown products is toxic or contains any virus, prion or other protein. It has
coherent porous structure, into which the new bone tissue (osteon) may grow. It breaks
down synchronously with the bone regeneration, and the resulting bone tissue exhibits a
structure similar to the original. It is transformed quantitatively into functioning bone.
TCP gives an X-ray shadow, whereby its fate can readily be followed.39
Collagen fibres and blood vessels invade the interconnecting micro-pores of the TCP
granules (micro-pores) and the intergranular cavities (macrospores).
The collagen fibres serve as a guide-rail for capillaries and newly formed bone and
stimulate the taking of the bone on the implant surface prior to the beginning of its
resorption.
Despite its high porosity, TCP possesses optimal stability and high abrasion resistance.
Its purity of phase provides a stable structure and homogenous solubility under
physiologic conditions. The primary-grain size of 10-63µm does not provoke
phagocytosis by macrophages.112-114 (Figures 20., 21.)
• As a purely synthetic material TCP is free from any risk of material-induced
infection.
• There is no immunologic defence reaction.
• The rounded surface of the TCP granules prohibits mechanical irritation of the
surrounding tissue and reduces inflammatory reaction.
• The physiologic pH-value in aqueous solution results in excellent
biocompatibility.
• The high mechanical stability of TCP prevents the premature degradation of the
material into micro particles and thus avoids undesirable macrophage activity.
• TCP is integrated into the natural bone without connective tissue encapsulation
or tissue degeneration.
• ß-Tricalcium phosphate is a highly osteoconductiv material.

29
Fig. 20. β-tricalcium phosphate (25x) Fig. 21. Alloplastic graft: β-tricalcium
phosphate

4.3 - XENOGENEIC BONE MATERIAL

When the organic material is removed from xenogeneic bone, a special mild
treatment must be used to preserve the original composition and structure of the
inorganic substance.
The technical process used in producing the xenograft from a bovine bone source makes
possible the removal of all organic components of the bone product, leaving a pure,
nonorganic bone matrix in unchanged inorganic form avoiding the risk of BSE or other
virus transmission too.
Anorganic Bovine Bone (ABB) is a finely crystalline, carbonated apatite practically
identical to natural human bone mineral.1,115,116 The chemical extraction process makes
possible the desirable properties of this material. The implantation of ABB in surgical
sites leads to ample formation of well-vascularised new bone, which integrates with the
ABB particles to restore proper structure and function in the defect site.
The resulting high bone-to-matrix ratio gives the surgeon an excellent basis for
operations involving use of titanium root-form implants or orthopedic devices in
reconstructive or orthognathic surgery.

30
The chemical composition of a graft material influences the rate and extent to which it
is incorporated into the host tissue and the subsequent physical characteristics of the
graft site.
Even more important is the crystalline structure of biomaterials. ABB bone consists of
very tiny crystals similar to those of human bone. The small crystals are represented in
x-ray diffraction analysis by broad spectrum. (Figure 22.)

Fig. 22. Deproteinized bovine bone cristal (50x)

Absence of any protein in the bone substrate materials is important to be certain that no
allergic or immunologic reaction occurs after implantation of the xenograft material in
human patients. The complete removal of all organic materials is confirmed for each
batch of ABB material produced.
Investigations have shown ABB to have a natural morphologic structure; a chemical
composition identical to that of bone; a large inner surface and porosity comparable to
that of bone; a crystalline structure identical to that of bone tissue; and a composition
that is purely anorganic.
The biologic character of the xenograft has been examined in a number of animal and
clinical experiments. The ABB spongiosa offers greater space for the regeneration of
new bone tissue and seems to be one of the best materials of choice for the regenerative
process in the maxilla and the mandible. The enlargement of histologic views showed,
for both ABB spongiosa and ABB cortical bone, internal pores that are filled by new
bone. Porous areas with diameters of approximately 80 μm and more were invaded by
new bone.

31
To distinguish between the blood vessels from ABB and those newly formed bone,
Schenk used a different staining method.25 The number of blood vessels penetrating a
ABB cortical particle was impressive and demonstrated the revascularizing and
remodelling of the anorganic material through the invasion of blood vessels and new
bone. Spector implanted ABB in 30 rabbits and evaluated the results after 10, 20, and
40 days.1 As a control, synthetic calcium phosphate was used. These results were
evaluated by histomorphometric methods.
The structure of the material varies significantly from the surrounding bone spongious
structure. In contrast, 1 week after implantation of ABB, osteoblasts are lining up and
starting the mineralization process to form new matrix.
A line of osteoid tends to form, embedding the osteoblastic cells in the mineral matrix.
The osteoid covers the ABB surfaces and represents the first immature bone.
This bone formation continues and will lead to the union of bone matrix and ABB
particles across the defect to the walls of the host defect. Six weeks after implantation,
the newly formed bone is interconnecting the ABB particles. The bridging by new bone
is leading to the stabilization of the host bone in the defect area. The particles are
difficult to recognize and distinguish from the surrounding bone tissue because of the
intense proliferation of new osseous repair matrix.
Indications of the resorption process can be identified by osteoclasts on the Anorganic
Bovine Bone surface next to areas of bone formation. Bone is a living tissue that usually
is transformed by approximately 2% to 3% per year by a constant remodeling process.
In surgical defects, however, the bone may remodel faster from the woven bone, and the
transforming process to lamellar bone may occur completely within several months,
depending on various factors involving graft site, vascularity, and functional forces.
Resorption lacunae were also reported in human histologic specimens examined by
Shenk.25 The cylinder shows reconstruction of the cortical crest with underlying
spongiosa structures. ABB is integrated in the newly formed lamellar bone. The lacunae
in the ABB particles are filled with new bone next to osteoclasts, indicating an ongoing
remodeling process.
These data indicate that the resorbing remodeling process may go on for years. This has
also been confirmed in various investigations of humans material. The initial integration
of ABB into lamellar structures can be seen in the specimens. Later the resorbing

32
process follows, involving the surrounding bone in a delayed remodeling process. The
resorption, remodeling and new bone formation process is prolonged by the presence of
residual ABB particles, thus assuring a constant bone matrix density, an increase in
bone density, and an increase of the thickness and quantity of osseous trabeculae and
bone cortex. Boyne has shown that the slow resorption and remodeling of porous bone
mineral imparts a high degree of permanency to the restored mandibular edentulous
area. The physical and chemical properties of porous bone mineral (ABB) are host
compatible, offering excellent conductive surfaces for the promotion of bone repair.
(Figure 23.)

Fig. 23. Xenogeneic graft: Anorganic Bovine Bone.

33
5. – BONE GRAFTS AND SUBSTITUTES: MECHANISM

The use of bone grafts involves three mechanisms: conduction, induction, and
guided tissue regeneration, which formerly was termed osteophylic response. All are
involved in bone regeneration.1,85,117

5. 1 – BONE CONDUCTION

Conduction involves the use of inert bone substitute materials or nonviable

autogenous and allogeneic banked bone grafts, which offer little or no inductive
stimulation to the pluripotential cells of the host defect but do serve as scaffolding over
which the bone-forming cells of the host may grow. Particulate conductive materials
can be placed, for example, between the root-form implant and the tooth extraction
socket wall so that the bone repair can more rapidly proceed from the socket wall to the
implanted surface, stimulating bone formation and integration of the root-form implant.
Thus, conduction is used mostly in those defects in which there are three bony walls and
in surgical sites in which a good supply of osteoblastic cells is provided by the bony
walls.
Conductive materials alone should not be used on single bony surface, such as the crest
of the alveolar ridge, in an effort to encourage bone to grow outwardly from that bone
interface. In this situation, the supply of osteoblasts available is not able to produce the
osteogenesis necessary to regenerate bone on the surface of the edentulous alveolar
ridge; therefore, a highly inductive bone graft material that supplies the pluripotential
cells necessary to regenerate the area should be used. Thus, for example, an iliac-crest
bone graft with cancellous bone and high inductive capacities should be used to
regenerate the ridge height of large edentulous areas. Therefore it is felt that inductive
autograft material, in conjunction with conductive material, should be considered a
necessary part of such grafting procedures.118
If bone grafts are used in children for cleft palate repair, the growth of the child and the
large numbers of pluripotential cells available in the growing child’s bony surfaces are
conductive to “induction” of the bone graft material, and to a favourable result. Thus,

34
the bony recipient site itself can be “inductive”. Clinicians are conditioned to think that
it is necessary to add something to the bone graft (eg, exogenous growth factor
materials) to produce the inductive effects. However, the recipient site itself may serve
as an inductor of the bone reparative cells.101
Conductive materials are used in three major areas of clinical concern:
1. In two- or three-walled bony defects with ample supply of pluripotential cells
2. As a carrier for bone inductors, eg, as a substrate for rhBMP-2 that releases the
inductor over an appropriate period of time
3. To increase bone density and to produce slow remodeling in the area. This
remodeling ensures both the prolonged presence of bone mineral and a thickened
trabecular pattern for a protective response to the occlusal and functional changes that
may occur in the lifetime of the root-form implant.

5.2. – BONE INDUCTION (PROTEIN-BMP)

One of the bone growth factor materials that can bring about induction of bone
in areas in which bone regeneration would not normally occur (the crest of the ridge of
the maxilla) is rhBMP-2. This material can be obtained in a highly refined form by
genetic engineering using recombinant DNA.119 This growth factor, when used in a
surgically appropriate manner, is able to stimulate the pluripotential or precursor cells of
the existing host wall and even the pluripotential cells in the cancellous portion of any
bone graft that may be placed along with the inductor material. In addition, rhBMP-2
may be simply placed on a carrier without any concomitant use of autogenous
cancellous bone at the time.
Regeneration of large critical sized discontinuity defects by use of rhBMP-2 in a simple
collagen sponge has been demostrated. Such restored hemimandibulectomy defects in
Macaca fascicular is have been shown to support root-form implants in full function for
6 to 8 months. Bone morphogenetic protein-induced bone in the antral floor of patients
also has supported implants for prostheses. In the past, demineralized freeze-dried bone
has been used by some surgeons on the premise that it is an “inductive material”.10,15
However, there is very little inductive capacity in demineralized freeze-dried bone,
because there is very little BMP in the product. Therefore, the effect of demineralized

35
bone powder is primarily one of conduction and not induction. This material should not
be used in an effort to build bone superiorly on the crest of the ridge of the maxilla or
the mandible, unless it is used in conjunction with the autogenous bone grafts of the
type previously described or as a carrier for true BMP in the concentrated, recombinant-
DNA-produced biologic form (rhBMP).
The growth factor rhBMP-2 is both a mitogen and a morphogen, and its functions are
both to recruit progenitor cells and to morphologically change cells to the osteoblastic
line of cellular maturation to produce bone. Such an effect may be needed for a short or
long period, depending on the defect being regenerated. Carrier materials for rhBMP
can be designed for a short-term, a medium-term, or a long-term effect, depending on
the desired time of release of the rhBMP in the regenerating area.
Examples of materials that will carry rhBMP and be degraded over a short period (2 to
4 weeks) are collagen sponge and various degradable alloplastic materials (eg,
polylactic acid and plyglycolic acid). Carriers that will release rhBMP over a slightly
longer period are more slowly degradable. This class of materials would include such
substances as calcium carbonate and tricalcium phosphate. Carriers that will release
rhBMP over a long period are those that are slowly remodeled and resorbed, such as
porous bone mineral (ABB).
Examples of carriers that are relatively inert and degraded very slightly, or not at all,
HTR (hard tissue replacement), which is a polyhydroxyethyl methacrylate (PHEMA)
product in the form of beads, and certain types of porous hydroxyapatite.
Thus, a significant part of the clinical effect of the use of rhBMP may be determined by
the degradability and other characteristics of the carrier itself. It is believed that the best
type of carrier for rhBMP surrounding a root-form titanium implant may be a material
that is slowly degradable, providing prolonged bone induction and availability for
remodeling to obtain a higher density of cancellous bone resistant to future bone
resorptive processes.18,85

5.3 - GUIDED TISSUE REGENERATION

The term guided tissue regeneration is now used to describe the phenomenon in
which alloplastic membrane surface exclude various types of cells from a surgical

36
defect site.1,120 This phenomenon, formerly called osteophylic response, was used
extensively, beginning in 1965, in connection with bone grafting of large trauma-
induced, and postoncologic defects. The effect of the membrane depends on its pore
size. If the pores are large, many of the cells (including fibroblasts) that the surgeon
usually wishes to exclude will migrate through, allowing soft tissue, instead of new
osseous matrix, to form in the bony defect. Normally a membrane with pores on the
order of 0.5 µm is used; one with pores of 100.0 µm or more would allow a great many
unwanted cells to enter the regenerating defect area.
Whether a membrane-type barrier should be used in bone grafting for regeneration of
the maxilla, for example, depends on the type of prosthetic restoration to be used. If the
area is to be restored with a removable prosthesis requiring a deep vestibule for
retention, a membrane should not be used because membranes tend to prevent a new
periosteum from forming underneath the titanium next to the generating bone. Without
the new periosteum, it is not possible to reposition the oral mucosa by suturing the
mucosal flap at a superior level to recostruct the vestibule after the removal of the
titanium mesh.121,122
If a membrane is not used with the titanium mesh, a new periosteal surface forms
beneath the metal and overlying the regenerating bone. This newly formed periosteum
will be thick and nonfriable and will retain the sutures used to attach the mucosa to
produce an excellent vestibular height when the metal mesh is removed after 3 to 5
months. This vestibule-producing technique is really a secondary epithelialization
procedure.
If the surgeon and the prosthodontist are restoring the area with root-form implants and
a fixed prosthesis, a deep vestibule is of lesser importance. If root-form implants are
being used, a membrane may be placed inside the titanium mesh and the mucosa merely
closed over to the crest of the ridge following the removal of the mesh. The optimal
effect of the membrane is to exclude the ingrowth of fibrous tissue, thereby increasing
bone formation. However, if the use of the membrane would prevent the surgical
development of a desirable vestibule, then the membrane should not be used.
Membranes should not be used when there are insufficient bony walls to provide the
critical mass of precursor cells necessary to form bone. If the surgical defect has only
one bony wall with very few cells available for osseous regeneration, the effect of the

37
membrane would be to exclude the pluripotential precursor cells from the periosteal
flap, thus excluding the necessary additional pool of cells that would be available if the
membrane were not used. Therefore, the filter or membrane should not be used when
there is only one bony wall with a poor blood supply that offers a diminished number of
cells to regenerate the defect.118
If, however, the defect has a minimum of three bony walls with excellent vascularity
and a good reservoir of pluripotential cells from the host bone available to be induced to
form osteoblasts and bone, the membrane may be used. The cells from the periosteum
can be excluded, because they will not be necessary for appropriate regeneration of the
defect. An excellent example of a complete, functional, and anatomically correct
reconstruction of a large defect is the using the membrane system. 123-126
When, cells from the mucoperiostel flap are excluded, a large amount of fibrous tissue
will be prevented from entering the bone-regenerating area; this effect will contribute to
an excellent result when used in an appropriate surgical bone site. For enhancement of
bone density in the final reconstructive product, a 50-50 mixture of PMBC with
Anorganic Bovine Bone and Tricalcium phosphate have been found to be most
effective.127 (Figure 24.)

Fig. 24. (a) Implants inserted in a narrow alveolar ridge with exposed threads and
(b) non-resorbable Titanium reinforced membrane

38
6. – MATERIALS AND METHODS

6.1 - MATERIALS AND METHODS: SINUS ELEVATION

Twenty edentulous patients were scheduled for bilateral sinus floor grafting at the
following 4 centres:
1. Semmelweis University, Department of Oral and Maxillofacial Surgery,
Budapest, Hungary
2. Dental and Stomatologic Clinic, Department of Oral Surgery and Oral
Implantology, University of Milan Italy
3. Department of Oral and Maxillofacial Surgery, Manchester Royal Infirmary,
Manchester, United Kingdom
4. Periodontology, Oral Implantology, Dento-Alveolar Surgery Clinic, Brugge,
Belgium

At each centre, identical protocols were followed for patient selection,

preoperative examinations, surgical procedure, implantation, biopsy specimen removal,
postoperative treatment, and patient follow-up. In 10 cases, the operation was combined
with onlay bone grafting.
All of the patients had conventional denture retention problems because of severe
anterior and posterior maxillary alveolar ridge atrophy. All had a residual sinus floor
less than 5 mm high (using the Cawood and Howell classification);128,129 bone loss was
3 to 4 in 3 of the 20 patients, 5 in 7 patients, and 5 to 6 Howell class in the other 10
patients). In 10 patients, the maxilla was atrophied to such an extent that sinus grafting
alone was insufficient; in these case, a large section of the residual alveolar arch had
thinned to a knife edge in the horizontal and sagittal directions. The patient population
consisted of 9 men and 11 women who ranged in age from 38 to 67 years (mean 52
years). After routine oral and physical examinations, the patients were selected and bone
reconstruction procedures were planned. In 10 patients, the reconstruction included only
bilateral sinus floor grafting; in the other 10 patients, bilateral sinus grafting was

39
performed, with onlay bone grafting in the anterior and part of the posterior maxilla,
followed by implant placement 6 months later.
All of the patients were healthy, with no disease that might influence the treatment
outcome. The patients were fully informed about the procedures, including the surgery,
bone-substitute material, and implants. They were asked for their cooperation during
treatment and research; all gave their written informed consent. The ethics committees
of the various institutions approved the research protocol.
Routine panoramic radiographs were obtained in all cases pre- and postoperatively, 6
months after the first surgery (prior to implant placement), and immediately after
implant placement. Additional panoramic radiographs were taken at 6-month intervals
after implant placement. Moreover, in the 10 patients in which onlay bone grafting was
performed, 2D and 3D examinations were performed pre- and postoperatively and 6
months after implant placement, using a General Electric Pro- Speed Plus (General
Electric Medical Systems, Milwaukee, WI). The lateral exposures were taken in the
same plane and direction as the preoperative ones.
In all 20 patients, surgery was performed under general anesthesia. Before or at the time
of sinus grafting, 5 to 6 cm3 of spongious bone were harvested from the left iliac crest
by a second team of surgeons. In the cases that included onlay grafting, the spongiosa
was removed together with a piece of cortical bone about 3 cm wide and 4 to 6 cm long.
The bilateral sinus grafting procedure followed Tatum’s classical description.130 A door
was created with a round hollow bur in the lateral maxillary sinus wall. After
mobilization, the door was reflected inward. On one site, the sinus-elevation space was
filled only with 1.5 to 2 g of β-TCP (particle size 1,000 μm); on the other side, it was
filled with 3 to 4 cm3 of autogenous bone. The TCP side was the experimental side; the
autogenous bone side was the control side. The choice of sides was randomized using
the coin-toss method. In 12 of the 20 patients, the experimental side was on the right; in
8, it was on the left.
In 10 of the 20 patients, it was necessary to widen the alveolar crest, which had become
extremely thin in places. This was performed at the same time as the bilateral sinus
grafting. The harvested cortical bone was attached to the buccal side of the
compromised maxilla using microscrews.

40
Next, the uneven bone edges were smoothed with spongiosa, the buccal and labial
periosteum was extended in the customary way, and the wound was closed in a tension-
free manner. No membrane was used to cover the bone. The sutures were removed 7 to
10 days later. The following postoperative regime was applied to avoid infection:
ciprofloxacin 500 mg 2 times daily for 5 days and ibuprofen 400 mg 3 times daily to
reduce pain and swelling. The patients were instructed not to wear removable prostheses
for 30 days and not to blow their noses for 7 days.
After 6 months of healing, the patients received implants. Eighty cylindric bone biopsy
specimens were taken from the grafted posterior maxilla (2 from the experimental side
and 2 from the control side in every patient) using a trephine bur with an inner diameter
of 2 mm and an outer diameter of 3 mm. After biopsy specimen removal, osteotomy
sites were prepared for implant placement. In 4 patients, 16 Protetim implants were
placed at the sinus elevation sites. In the other 16 patients, 64 Ankylos implants were
used. In addition to the 80 implants placed at the sites of the β-TCP or autogenous bone
grafts, many more implants were required for the complete rehabilitation of the
edentulous maxillae of the 20 patients, but the remaining implants were not directly
related to this study.
The bone biopsy samples contained both the grafted area and the previously existing
area of sinus floor, but the residual native crestal bone was not included in the histologic
and histomorphometric examinations. Cortical bone in samples from patients with onlay
grafts was not included either. Biopsy samples from all 4 centres were fixed in 4%
formaldehyde and then submitted for histologic examination to the oral pathology unit
of the Department of Oral and Maxillofacial Surgery of Semmelweis University. The
bone samples were processed and stained as reported earlier.6Briefly, they were fixed in
4% formaldehyde in phosphate buffer, dehydrated in an ascending series of graded
alcohols, and embedded in methylmethacrylate resin at 4°C. Five-μm-thick histologic
sections were cut in the longitudinal plane with a diamond knife and stained with
toluidine blue and hematoxylin-eosin. Goldner’s trichrome method was used for light
microscopy.
The β-TCP particles were achromatic. If they had broken out of the section, their places
were recognizable because of their characteristic shape and size, or because of the

41
granule remnants at the interface between the β-TCP granules and the surrounding
tissue.
Morphometric studies were performed according to the principles of Parfitt and
colleagues.131 Sections of each sample were taken for histomorphometry from 4 levels
at 150-μm intervals. The samples were measured semiautomatically using an Olympus
microscope (Olympus, Tokyo, Japan) connected to a computer using Analysis software
(Soft Imaging System, Münster, Germany). The total surface area of each sample, the
surface area that consisted of bone, and the area that consisted of graft material were
measured in mm2, and bone and graft material were analyzed as a percentage of the
total. Bone from the original sinus floor was not involved in the bone area
measurement.
The Student t test was used to determine statistical significance. Values of P<.05 were
considered significant.

6.2 – MATERIAL AND METHODS: ECTODERMAL DYSPLASIA

In Ectodermal Dysplasia study, 186 titanium implants associated with guided

bone regeneration (GBR) were placed in 33 patients. All the patients were nonsmokers.
The ED patient group consisted of 13 patients, nine men and four women, aged 16–45
years, all with reduced vertical dimension or skeletal deep-bite. Sixty-six implants were
placed in this group, 15 in the upper jaw and 51 in the lower jaw, and GBR was used for
local bony dehiscence and fenestration defects. Ten bioabsorbable membranes and 21
non-resorbable membranes were used. The non-ED patient control group comprised 20
patients, 11 men and nine women, aged 16–68 years, selected with the same dentofacial
features as the ED patients: hypodontia or missing teeth with reduced occlusal and
skeletal vertical dimension (15 skeletal deep-bite and five normovertibite, no open-bite),
decreased alveolar bone, with a typical old-age appearance and poor aesthetics of the
face. Both groups had a severe lack of the alveolar ridge in both height and width,
corresponding to edentulous sites. All the mandibular alveolar ridges had a knife-edge
contour, which usually makes ideal implant placement difficult without GBR and bone
grafts.

42
In the non-ED group, 36 fixtures were placed in the maxilla and 84 in the mandible.
Ninety-three of the recipient sites were associated with localized bone defects or
insufficient alveolar ridge width resulting in exposed fixture threads at installation.
Twenty-two bioabsorbable membranes and 34 non-resorbable expanded
polytetrafluoroethylene (e-PTFE) membranes were adapted to cover the exposed threads
at buccal fenestration and dehiscence defects. To produce bone regeneration, GBR was
applied in combination with autogenous bone and Anorganic Bovine Bone.
( Figure 25.)

a b

c d
Fig. 25. Guided bone regeneration by non-resorbable membrane and Anorganic
Bovine Bone mixed to autogenous bone. (a-b-c-d)

Two-stage surgery was used, with a 6- to 8-month healing period before functional
loading.
Together with radiographic evaluations, the following clinical parameters were
assessed around the fixtures: probing depth (PD) (mm) (mesial, distal, buccal, and
palatal); peri-implantitis; mucosal recession; modified plaque index (mPLI) and
modified sulcus bleeding index (mSBI); clinical mobility; and Periotest value before
final prosthetic rehabilitation and after 3 years, when implant bridge removal was
possible.132 (Figure 26.)

43
 Fig. 26. Second stage surgery after 6 month healing
period.

After delivering the prosthetic-implant reconstructions, the patients were involved in a

maintenance care program, in accordance with individual needs. (Figure 27.)

Fig. 27. Temporary and final implantological- prosthetic rehabilitation

44
7. – RESULTS

7. 1 – RESULTS: SINUS ELEVATION

After sinus elevation, no postoperative complications occurred in any of the

patients. Normal wound healing was observed after both the first and second operations
(graft harvesting/sinus elevation and implant placement). Minor nose bleeds occurred in
3 patients.
One patient had permanent sensory loss in the distribution of the lateral femoral
cutaneous nerve, and 2 patients had prolonged wound drainage (2 to 3 weeks). No other
postoperative complications were observed in conjunction with the donor sites.
Panoramic Radiograph. Three panoramic radiographs were compared for every
patient: 1 taken shortly after graft implantation surgery, 1 taken at 6 months
postoperatively (at implantation), and 1 taken 12 months postoperatively (ie, at
suprastructure fabrication). These radiographs clearly showed the positions of both
types of graft material and the height of the new sinus floor.
The autogenous bone was initially less visible than the β-TCP, but new bone formation
was clearly observed for both materials. The consecutive images also revealed changes
in the graft materials and their incorporation. β-TCP was markedly more radiopaque
than autogenous bone.
After 6 months, the β-TCP had changed slightly in the radiographs: the contour of the
bone around the graft became more defined. After 12 months, the graft was similar to
bone because of absorption of the β-TCP and the simultaneous formation of new bone.
Computerized Tomography. A comparison of the panoramic radiographs and CT
images in 10 patients revealed the advantages of supplementing the panoramic
radiographs with 2D CT images. In planning the surgery, the thickness and width of the
alveolar bone and the process of new bone formation could be better assessed in this
way. The 3D CT reconstruction best revealed the postoperative sinus graft height and
new sinus floor, as well as the ossification process. (Figures 28., 29.)

45
 Fig. 28.a Preoperative 3-dimensional (3D) computerized tomogram (CT)
demonstrating that a large part of the alveolar crest has atrophied

Fig. 28.b Preoperative 2-dimensional (2D) CT. Using the classification of Cawood and Howell
the bone loss grade was 6 (the height of the residual sinus floor was less than 2 mm)

Fig. 28.c Postoperative 3D CT. The bilateral sinus grafts are clearly visible
(β-TCP in the right maxilla and autogenous bone in the left maxilla)

Fig. 28.d 3D CT reconstruction. The onlay bone grafting is clearly

visible

46
 Fig. 28.e Panoramic radiograph 6 months after the sinus grafting. Ankylos implants
were placed

Fig. 28.f One year after sinus grafting, after prosthetic rehabilitation. The β-TCP
graft (right) appeared similar to bone

a b
Fig. 29.a and 29.b Preoperative (a) 2D and (b) 3D CT scans. The right side of the residual alveolar
crest has thinned to a knife edge in the horizontal and sagittal directions. The 2D CT clearly
reveals the situation of the residual sinus floor.

c
Fig. 29.c After sinus grafting and onlay bone graft. The heads of the microscrews are
visible in the right and middle parts of the maxilla

47
 d
Fig. 29.d Three- dimensional CT 6 months after onlay bone grafting; bone
integration is clearly visible

e
Fig. 29.e Twelve months after the first surgery, prosthetic rehabilitation
of the Protetim implants was completed. With absorption of the β-TCP
and the simultaneous formation of new bone, the grafted areas have become
similar to bone

In the biopsies from the experimental side, the β-TCP graft was identified as
achromatic rounded or scalloped granules, depending on the phase of resorption. They
were partially embedded in newly formed bone, which was predominantly lamellar
bone. (Figure 30a.)
Bone formation was preceded by the abundant proliferation of a cell-rich osteogenic
mesenchyme and a new capillary network in the pores of the resorbing granules. (Figure
30b.)

48
Fig. 30.a Fig. 30.b
β-TCP graft and new bone formation. Osteogenic mesenchyme growing on the surface
CG = β-TCP granule; and in pores of a β-TCP granule.
B = new bone CG = β- TCP granule;
S = soft tissue (toluidine blue; original magnification x2) B = bone
OM = osteogenic mesenchyme (toluidine blue; original
magnification x25)

Newly formed bone replaced the resorting β-TCP particles continuously. Bone
deposition characteristically occurred along the surface and in the pores of the
disintegrated graft material. There was no foreign body-type giant cell reaction in the
grafted samples. In 1 sample, there was a focal lack of bone formation and an intense
inflammatory reaction, suggesting a local infection.
The majority of the biopsy samples from the control side contained mature lamellar
bone. (Figure 31a.)
The bone trabeculae contained osteocytes in their lacunae. Signs of dynamic bone
formation with osteoblast activity or lacunar osteoclastic resorption were rare. The
remnants of the autogenous bone grafts could be seen in several foci as homogeneous
tissue fragments that stained like living bone. (Figure 31b.)

49
Fig. 31.a Fig. 31.b
Autogenous bone graft and newly formed Bone graft focus and newly formed
lamellar bone. lamellar bone.
B = bone B = bone
BG = bone graft BG = bone graft
S = soft tissue (Goldner’s trichrome; original magnification x2) S = soft tissue (Goldner’s trichrome;
original magnification x25)

In these samples, there was intimate contact between the graft particles and new bone.
Several samples were typified by torpid bone formation, a predominantly fibrous bone
marrow, and a diffuse, thin network of bone trabeculae.
The mean percentage of bone area for the 20 patients was 36.47% ± 6.9% on the
experimental side and 38.34% ± 7.4% on the control side; the difference was not
significant (P = .25).
In a majority of the patients (n = 13), the intensity of new bone formation was similar
on both sides. When the volume occupied by the graft remnants was considered, these
data suggest that the bone density was sufficient on both sides. (Table 1.)

50
Tab.I.

51
Nevertheless, the new bone was markedly less dense on the experimental side in 4 of
the 20 cases compared to the control side (H2, B2, B4, l1). In 1 of these patients, the
lethargic bone formation process could be explained by a local inflammatory reaction.
In the other 3 cases, the percentage of the graft area was quite high (H2 25.9%, B4
25.6%, l1 21.1%), ie, the graft material took up too much space in the bone samples.
The bone-forming capacity on the control side was more sluggish than on the
experimental side in 3 cases (H5, H7, B3). In these cases, no inflammatory reaction or
delayed graft resorption hampered bone regeneration. In 2 cases (H1 and B1), the
ossification process was uniformly weak on both sides; the respective percentages of
newly formed bone were 25.6% and 27.5% on the experimental side and 24.0% and
28.1% on the control side. In these 2 cases, the new bone trabeculae were uniformly
thin, with no focal inflammatory lesion.
The rate of graft resorption was generally lower on the experimental side than on the
control side. The mean graft area percentages were 13.95% ± 5.38% and 8.47% ±
3.17%, respectively, and the difference was highly significant (P< .001).
The mean areas of the biopsy samples taken from the 2 sides were quite similar: 9.18 ±
2.42 mm 2 on the experimental side and 8.98 ± 1.76 on the control side.
In the 6-month period between implantation and loading of the implants, 2 of the 80
implants were lost (both Ankylos); 1 on the experimental side and 1 on the control side.
Both were replaced, but delivery of the definitive restoration was delayed by 3 to 6
months.

7.2 – RESULTS: ECTODERMAL DYSPLASIA

In the Ectodermal Dysplasia study group, the patients were evaluated at the
second-stage surgery, after prosthetic reconstruction, and after 1-, 2-, and 3-year follow-
ups. Almost all of the patients had a good level of oral hygiene, which was reflected by
the low mPLI and mSBI scores. Peri-implant mucosal complications, in which the
implant threads were not covered, were observed in patients with less-optimal oral
hygiene.

52
In the ED patient group, of the 66 fixtures inserted, 60 were associated with clinically
healthy peri-implant soft tissues, low bleeding scores, and minimal probing depths,
without signs of inflammation, suppuration, mucosal irritation, or increased mobility.
Radiographic evaluation demonstrated that these 60 fixtures were osseointegrated
because of the absence of peri-implant radiolucency. Only three membrane-treated
implants showed mucosal recession and intraoral exposure of the first buccal fixture
thread. Six implants were lost: two in the upper jaw and four in the lower jaw; four
during the healing period and two following functional loading. In this clinical study,
the ED patients had a 91% successful osseointegration rate of the installed fixtures. In
the non-ED control group, 115 osseointegrated implants showed no signs of pathology,
despite the intraoral exposure of threads in six cases. Only five fixtures showed
increased mobility and clinical instability at the second-stage surgery (three in the
maxilla and two in the mandible); these five fixtures failed.
The exposure of six membranes before complete healing led to observation of the
threads of the fixtures, indicating a loss of buccal bone. In another six fixtures, the first
thread was exposed, but without inflammation, mucosal irritation, or mobility. In the
non-ED control group, the 95.8% osseointegration rate was confirmed by the
radiographic evaluation and Periotest values.132
The two groups were compared statistically using the chi-square test. The
regenerated bone at peri-implant bony defects in the experimental group using GBR and
bone grafts responded in a similar way to the control group (Table II.). The
osseointegration rate and failure frequency of the two groups did not differ significantly
(χ2=1.86, p=0.1731; χ2 with the Yates continuity correction=1.08, p=0.2996)

Table II. Osseointegration Rate of ED patients vs non-ED patients.

χ2 with Yates continuity correction = 1,08 P= 0,2996

Patient Group Implants Inserted Implants Implants Lost Success Rate (%)
Osseointegrated
ED patients (n=13) 66 60 6 91%
Non-ED patients (n=20) 120 115 5 95,8%

53
8. - DISCUSSION

8.1 – DISCUSSION: SINUS ELEVATION

One of the most important conclusions of a Consensus Conference on sinus

grafting held several years ago133 was that, “retrospective analyses did not reveal any
bone substitute material that was equivalent to autogenous spongiosa...Accordingly,
many participants believed that autografts were the most efficacious....(but) the doubts
raised revealed the need for controlled prospective multicenter clinical trials”.
Therefore, since some authors had achieved good results with various bone-substitute
materials (especially ß-tricalcium phosphate [ß-TCP]), a prospective multicenter study
was initiated to shed more light on this question.
In a preliminary study6 involving bilateral sinus elevation in 4 patients in 2001 ß-TCP
was used on one side and autogenous bone on the other. Sixteen bone biopsy specimens
were taken at the time of implant placement. The aim of work was to compare 2
different graft materials, β-tricalcium phosphate and autogenous bone, when used in the
same patient. Evaluations were performed by means of 2- and 3-dimensional (2D and
3D) computerized tomography (CT) and histologic and histomorphometric
examinations. The duration of the study was 6 months, which is the usual waiting
period after sinus grafting. It was concluded that the implantation of ß-TCP was
followed by the formation of new bone of similar quality and quantity to that observed
after grafting with autogenous bone. The histologic and histomorphometric results
indicated that when new bone formation was slow, it was slow on both the ß-TCP side
and the autogenous bone side, and when it was rapid, it was rapid on both sides.
Individual patient factors strongly influenced the results.
In essence, the present study is a continuation of that previous work, but on a broader
basis. A prospective, multicenter study of 20 patients was organized to confirm the
findings of the initial study of 4 patients and to examine whether ß-TCP alone is a
suitable graft material for sinus elevation.
A number of articles have examined the significance of pure-phase ß-TCP53,112,114 and
other alloplastic materials7,9,15,26,117,-134-143 as bone substitute materials. However, very

54
few studies have involved bilateral sinus elevation with 2 different materials in the same
patient.
Tadjoedin and associates32 applied autogenous bone mixed with bioactive glass on the
experimental side and autogenous bone alone on the control side. They noted that
“bioactive glass particles in the size range 300 to 355 µm clearly show a bone-
augmenting capacity, and the cotransplantation of autogenous bone may not be
necessary for sinus floor augmentation”. This was somewhat contradicted by 2
publications by Yildirim and colleagues,144,145 who used a xenogenic bone-substitute
material, ABB first in combination with venous blood and later with autogenous
intraoral bone. The combination of osteoconductive ABB and osteoinductive
autogenous bone proved better for sinus floor augmentation than did venous blood and
ABB. In animal experiments, Mc Allister and coworkers115 demonstrated radiographic
evidence that bone density and height stability were maintained for 1.5 years after sinus
grafting with ABB. Valentini116 retrospectively evaluated the rates of survival of 2
different types of implants in sinuses grafted with inorganic bovine bone alone or with
inorganic bovine bone mixed with a demineralized freeze dried bone allograft. They
concluded that inorganic bovine bone used alone appeared to be a suitable material for
sinus floor augmentation. A meta-analysis by Wallace and Froum146 showed that there
was no difference in regard to implant survival between grafting with 100% autogenous
bone or grafting with composites that included autogenous bone as a component. In a
pilot study, Schmelzeisen and associates147 used tissue-engineered bone for sinus floor
augmentation. Their results suggested that periosteum-derived osteoblasts on a suitable
matrix form lamellar bone within 4 months, which allows reliable implantation.
Despite this encouraging research, in everyday practice most surgeons believe that no
matter what bone-substitute material is used, the results are always better if autogenous
bone is added. Since the autogenous bone must be taken from somewhere, a second
operation is necessary, which puts the patient at risk of donor site morbidity. This study
examined whether donor site morbidity can be avoided by using synthetic bone
substitute.
The primary aim of this work was to compare the implanted graft material using
clinical, radiologic, and histologic studies. Two of the 80 implants (2.5%) were lost, 1
from each side, suggesting the equivalence of the 2 materials. The comparison of the

55
bone-forming activity of β-TCP and autogenous bone confirmed earlier findings. New
bone production was similar on both sides; the difference between the 2 sides was not
significant. These results support the view that β-TCP can be a satisfactory graft
material, even without the addition of autogenous bone.
Radiologic examinations indicated that the grafted area changed in contour during the
period of study (from sinus floor augmentation to definitive prosthetic rehabilitation).
The vertical height of the grafts was not analyzed in the present study. Several factors
can influence new bone formation, in addition to the nature of the graft. In 2 cases (H1
and B1), the rate of new bone formation was low on both sides. This might be the result
of general factors, such as old age, hormonal dysfunction, or distrurbances in calcium
metabolism.
Local factors can explain 1-sided lethargic bone formation. Disturbances in the blood
supply or inflammation at the site of surgery can also delay bone regeneration. In the
present study, unilateral lower rates of bone formation were seen on the experimental
and control sides in different patients, which supports the important role of local factors.
The size of the biopsy sample can also influence the quantitative comparison of the
effects of the graft materials. The greater the area of the bone sample, the more
representative the quantitative measurement. In the present study, the areas of the bone
samples derived from the 2 sides did not differ significantly.
In the introduction, the question was posed whether, under certain conditions, a bone-
substitute material can be equivalent to the patient’s own spongiosa. These results
suggest a positive answer to this question.
In sinus elevation surgery, β-Tricalcium phosphate can be as effective as autogenous
bone. Naturally, this does not necessarily hold true for other operations. For instance,
inlay grafting should still be performed with autogenous bone.
This study investigated 20 patients. Strict patient selection was necessary, mainly for
ethical reasons. In the 10 onlay grafting cases, which required autogenous bone, use of
the control material could be justified. However, in those cases with no onlay grafting,
the question was not so clear-cut. The number of cases had to be restricted to the
minimum number necessary to drawn reliable conclusion. The examination of the 80
biopsy samples taken from the 20 patients led to unambigous findings. The conclusion
drawn appears to be supported by the clinical and radiologic data.

56
Initially, more working groups had been planned. However, 2 groups were forced to
withdraw from participation in the investigation because patients did not agree to the
excision of autogenous bone. This further demonstrates the importance of having a
suitable bone-substitute material. Onlay grafting was necessary in 10 of the 20 patients.
In these cases, the alveolar crest of the maxilla was so thin at many sites bilaterally that
stability of the implants could not have been ensured by sinus elevation alone. The
vertical augmentation had to be supplemented with horizontal augmentation. A porous
bone substitute is not very suitable for this purpose; on the other hand, cortical bone
taken from the hip is integrated into the outer surface of the maxilla within a few
months.
Onlay bone grafting clearly has no effect on the healing process following sinus
elevation, as one of the processes occurs on the outer surface of the maxilla, while the
other proceeds internally.
Regarding the question of spongiosa as the gold standard, while it is true that the quality
of new bone obtained using any of the bone substitutes may be compared with this as a
standard, this standard does have disadvantages. The most important of these are donor
site morbidity, the relatively high number of complications, the need for general
anesthesia, and the high costs of hospitalization.148
Niedhart and associated148 have given a clear picture of the cost: removal of the bone
requires an average of 30 minutes, a second surgical team, and an anesthesiologist.
These costs far exceed the price of the bone substitute. With careful surgical techniques,
the rate of complications may be reduced; nevertheless, it generally ranges from 20 % to
30%. When all these factors are taken into consideration, it appears important to avoid
the excision of autogenous bone whenever possible.
Mention must be made of the membrane question. On the basis of more than 40
publications, Wallace and Froum146 performed a comparative meta-analysis of the use
of barrier membranes over the lateral window. They found that implant survival rates
were higher when a membrane was applied. A long-term clinical, histologic,
histomorphometric, and radiographic study of the sinus elevation procedure led Tarnow
and coworkers149 to the following conclusions:
• Application of a barrier membrane tends to increase vital bone formation.
• Application of a barrier membrane has a positive effect on implant survival.

57
• Membrane application should be considered for all sinus elevation procedures.
As these findings were accepted, no membrane was used in the present study. In 10 of
the 20 patients, an onlay graft was applied on the lateral wall of the sinuses. This
autogenous bone served as a barrier to soft tissue invasion. In the interest of
comparison, in the other 10 cases no membrane was applied over the lateral window.
The tissue-engineering procedures mentioned in the introduction, which also aim to
minimize donor site morbidity, may be the procedures of choice in the future.
Obviously, if the application of tissue engineered bone becomes as routine as the use of
skin or mucosa, the debate over graft materials will become less relevant. This may take
considerable time, and at present, materials are needed that avoid the excision of
autogenous bone.
In addition, with regard to the publications by Skoglund and associates, 150, 151 Tadjoedin
and associates,32 and Yildirim and colleagues,144 which consider natural bone mineral,
bioactive glass, and so on, the present work did not set out to compare and contrast
individual graft materials. If “remodeling” is considered, pure-phase β-TCP used alone
appears to be a suitable material for sinus floor augmentation.

8.2. – DISCUSSION: ECTODERMAL DYSPLASIA

The dental treatment of patients with ED is important, since it involves ensuring

a normal diet, optimal dentofacial aesthetics and function, good speech, and appropriate
psychological and emotional development. Since this may be complicated, it requires an
interdisciplinary approach involving various branches of dentistry and medicine.
Prosthetic dental rehabilitation usually consists of different combinations of complete or
partial removable dentures, overdentures, and fixed partial dentures. The use of dental
implants has become an important, well accepted treatment for replacing missing teeth
in adults. Guckes et al. reported that the clinical integration rates of fixtures in the
mandibles of ED patients approached that of non-ED patients.152 Some years ago, the
implant position was often determined by the alveolar ridge anatomy, which sometimes
presented aesthetic problems and resulted in mucosal inflammation because of this
unfavourable position.153-155 Today, prosthetically guided implants are usually used to
improve the hard and soft tissue aesthetics. Many authors have obtained successful

58
clinical outcomes with guided bone regeneration (GBR) using the barrier membrane
technique, in combination with autogenous or heterologous bone during implant
insertion.120,121,123,124 The use of a space-maintaining biomaterial, such as autogenous
bone or Anorganic Bovine Bone, has increased the volume and stability of regenerated
bone. The length of time required for maturation of newly regenerated bone before
functional loading depends on the morphology and dimensions of the lesion,
vascularization, surrounding bone quality, and optimal oral hygiene. In larger defects,
the use of a non-resorbable membrane together with a bone graft and an extended
healing period is indicated.122,125,126,156
Ectodermal dysplasia is diagnosed from the patient’s appearance and symptoms.
An early diagnosis of Ectodermal Dysplasia in infancy or childhood is very important to
avoid severe complications and to improve the quality of life. The morbidity and
mortality depend on the absence or presence of eccrine and mucous glands. Recurrent
high fever (hyperpyrexia) may lead to brain damage, neurological complications, and a
mortality rate of up to 30% in infancy. Beyond early childhood, the life expectancy is
normal or slightly reduced. Both the oral and maxillofacial surgeon and the pediatric
dentist can help to detect these syndromes using clinical observations and radiographic
imaging. Jaw radiography is indicated for infants with a fever of unknown origin and
possible hypohidrotic ED. The teeth buds may be absent. If unusual dental
abnormalities and hypodontia are present at an early age, panoramic radiographs,
intraoral dental radiographs, teleradiographs, and radiographs of the hands and feet may
detect specific deformities.
Other general medical examinations used to reach the diagnosis include sweat
pore counts, the perspiration test, and a skin biopsy to demonstrate the absence or
hypoplasia of the sweat glands, hair follicles, and sebaceous glands; genetic studies to
localize genes or mutations in ED families; and the prenatal diagnosis of hypohidrotic
ED using fetal skin biopsies. A detailed anamnesis with a family history of Ectodermal
Dysplasia in other family members may lead to an early diagnosis. Arriving at the
diagnosis requires a multidisciplinary approach, since the treatment will involve many
specialists, including pediatricians, dermatologists, dentists, and oral maxillofacial
surgeons.157 Children with ED often have serious dental disease requiring necessary and

59
timely rehabilitative therapy beginning at the first phase of the manifestation of this
pathology.158-162
The precocious dental treatment is finalized to improve both functional and
aesthetic aspects, which include nutrition, phonetics, and emotional and psychological
factors. The disease involves growing children in whom the restoration of masticatory
function leads to remarkable benefits in their subsequent growth and development. The
absence of numerous dental elements inevitably involves an alteration of the articulation
of words, and numerous sounds are altered. The absence or reduction of dental elements
accents the sensation of difference felt by patients with Ectodermal Dysplasia with
respect to their peers. The goal of the dentist and oral surgeon is to recreate a harmonic
smile that gives a natural, pleasant appearance to the face.

60
9. - CONCLUSIONS

About sinus elevation, it was concluded that the grafting of β –TCP was
followed by the formation of new bone of similar quality and quantity to that observed
after grafting with autogenous bone. Comparisons with other studies reveal that β-
Tricalcium Phosphate is a satisfactory graft material, even without autogenous bone.
Since a second operation is not necessary, donor site morbidity can be avoided by using
β –TCP.
Notwithstanding the anatomic restrictions, titanium screw implants may be
inserted successfully in Ectodermal Dysplasia patients in association with GBR and
bone grafts to provide a very stable dentition, and improved chewing ability, speech,
and psychological and emotional well-being.
The novelty and originality of this research:
1. For the first time a multicenter study on a broader basis was organized to
examine whether β- TCP alone is a suitable graft material for sinus elevation.
2. Concomitantly on the same patient, two sinus elevations by two different bone
grafting materials were performed: β- TCP alone as the experimental side and
autogenous bone alone as control side.
3. Donor site morbidity was avoided by grafting β- TCP alone.
4. For the first time a study to assess the possibility to insert osseointegrated
implants associated to bone grafts and guided bone regeneration also in
Ectodermal Dysplasia patients was performed.
5. For the first time in a study about ED patients, implants also in the upper jaw
were included.

6. The improved appearance and self-confidence, with a better function helped ED

patients to become accepted by their friends and families and resulted in a better
quality of life.

61
10. - SUMMARY

Two different studies have been performed. The objective of the former was to
determine whether donor site morbidity could be avoided by using pure-phase β-
tricalcium phosphate (β-TCP). Bilateral sinus grafting was performed on 20 selected
patients; β-TCP 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. Eighty bone
biopsy specimens were taken at the time of implant placement. Histologically and
histomorphometrically, there was no significant difference (P=.25) between the
experimental and control grafts in terms of the quantity and rate of ossification.
Comparisons with other studies reveal that β-TCP is a satisfactory graft material, even
without autogenous bone. The objective of the latter was to verify if it is possible to use
osseointegrated implants in Ectodermal Dysplasia Syndrome (EDS) patients. Dental and
surgical-implantological treatment for EDS patients may be very complicated. Guided
Bone Regeneration (GBR) membrane technique associated to bone grafting was used to
facilitate placement of osseointegrated implants in a guided prosthetically position. Two
groups with the same bony anatomical features were assessed. The first consisted of 13
Ectodermal Dysplasia patients, where 66 implants together bone grafts and membranes
were inserted. In the second control group 120 implants with GBR were placed in 20
patients. The implants were controlled at second stage surgery, and at a follow-up of a 1
year, 2 and 3 years functional loading period. The results showed no statistically
significant difference in the osseointegration rate between the two groups. Despite
anatomical defects associated with decreased occlusal vertical dimension and the
diminished edentulous alveolar ridges, both in height and in width, osseointegrated
implants together GBR and bone grafts may be successfully used in EDS.

Garagiola U, Maiorana C, Ghiglione V, Marzo G, Santoro F, Szabò G. 2006:

Osseointegration and guided bone regeneration in Ectodermal Dysplasia patients.
J Craniofacial Surg 17(6) (in press)

62
Szabò G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabás J, Németh Z,
Hrabák K, Suba Z. 2005: A prospective multicenter randomized clinical trial of
autogenous bone versus ß-tricalcium phosphate graft alone for bilateral sinus elevation:
histologic and histomorphometric evaluation.
Int J Oral Maxillofac Impl 20(3):371-381.

Suba Z, Hrabák K, Huys L, Coulthard P, Maiorana C, Garagiola U, Szabó G. 2004 : A

ß-trikalcium-foszfát graft csontregeneráló hatásának hisztológiai és hisztomorfometriai
vizsgálata (multicentrikus tanulmány).
Orv Hetil 145:1431-1437. Hungarian

63
11. - BIBLIOGRAPHY

1. Buser D, Dahlin C, Schenk RK. Guided bone regeneration in implant dentistry.

1994 Quintessence Publishing.

2. Schmitz JP, Schwartz Z, Hollinger JO, Boyan B. Characterization of rat calvarial

non union defects. Acta Anat 1990;138:185.

3. Adell R, Lekholm U, Gröndahl K, Brånemark P-I, Lindström J, Jacobsson M.

Reconstruction of severely resorbed edentulous maxillae using osseointegrated
fixtures in immediate autogenous bone grafts. Int J Oral Maxillofac Implants
1990;5:233.

4. Kaban LB, Glowacki J. Induced osteogenesis in the repair of mandibular defects

in rats. J Dent Res 1981;60:1356.

5. Gottlow J, Nyman S, Karring T. Maintenance of new attachment gained through

guided tissue regeneration. J Clin Periodontol 1992;19:315.

6. Szabó G, Suba Z, Hrabák K, Barabás J, Németh Z. Autogenous bone versus

beta-tricalcium phosphate graft alone for bilateral sinus elevations (2- and 3-
dimensional computed tomographic, histologic, and histomorphometric
evaluations): Preliminary results. Int J Oral Maxillofac Impants 2001;16:681-
692.

7. Becker W, Becker BE, Caffesse R. A comparison of demineralized freeze-dried

bone and autologous bone to induce bone formation in human extraction sockets.
J Periodontol 1994;65:12:1128-1133.

8. Bereiter H, Melcher GA, Gautier E, Huggler AH. Erfahrungen mit Bio-Oss,

einem bovinen Apatit, bei verschiedenen klinischen Indikationsbereichen. In:

64
 Huggler, AH, Kuner EH (eds). Hefte zur Unfallheilkunde. Vol. 216: Aktueller
Stand beim Knochenersatz. Berlin: Springer - Verlag, 1991:117-126.

9. Boyne PJ, James RA. Grafting of the maxillary sinus with autogenous marrow
and bone. J Oral Surg 1980;38:613-616.

10. Boyne PJ. Comparison of Bio-Oss and other implant materials in the
maintenance of the alveolar ridge of the mandible in men. In: Huggler AH,
Kuner EH (eds). Hefte zur Unfallheilkunde. Vol 216: Aktueller Stand beim
Knochenersatz. Berlin: Springer - Verlag, 1991;216:98-103.

11. Burchardt H. Biology of bone transplantation. Orthop Clin North Am

1987;18:187-196.

12. Donath K. The implantation of bone replacement materials. Dtsch Zahnärztl Z

1988;43:16-21.

13. Hollinger JO, Battistone GC. Biodegradable bone repair materials. Synthetic
polymers and ceramics. Clin Orthop Rel Res 1986; 207:290-305.

14. Hürzeler MB, Quinones CR, Kirsch A, et al. Maxillary sinus augmentation using
different grafting materials and dental implants in monkeys. Part I. Evaluation of
anorganic bovine-derived bone matrix. Clin Oral Implants Res 1997;8:476-486.

15. Jensen SS, Aaboe M, Pinholt EM, Hjørting-Hansen E, Melsen F, Ruyter E.

Tissue reaction and material characteristics of four bone substitutes. Int J Oral
Maxillofac Implants 1996;11:55-66.

16. Kasperk CH, Ewers R. Tierexperimentelle Untersuchungen zur

Einheilungstendenz synthetischer, koralliner und aus Algen gewonnener
(phykogener) Hydroxylapatit-materialien. Z Zahnärztl Implantol 1986; 2:242-
248.

65
17. Reddi AH, Weintroub S, Muthukumaran N. Biologic principles of bone
induction. Orthop Clin North Am 1987; 18(2):207-212.

18. Terheyden H, Jepsen S, Möller B, Tucker MM, Rueger DC. Sinus floor
augmentation with simultaneous placement of dental implants using a
combination of deproteinized bone xenografts and recombinant human
osteogenic protein-1. Clin Oral Implants Res 1999;10:510-521.

19. Wood RM, Moore DL. Grafting of the maxillary sinus with intraorally harvested
autogenous bone prior to implant placement. Int J Oral Maxillofac Implants
1988;3:209-214.

20. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus
Conference of 1996. Int J Oral Maxillofac Implants 1998;13(suppl):11-32.

21. Gerngross H, Burri C, Kinzl L, Merk J, Müller GW. Komplikationen der

Entnahmestelle autologer Spongiosatransplantate. Aktuel Traumatol
1982;12:146-152.

22. Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop
Traum 1989;3:3:192-195.

23. Groeneveld EHJ, van der Bergh JPA, Holzmann P, ten Bruggenkate CM, Bram
Tuinzing D, Burger EH. Histomorphometrical analysis of bone formed in human
maxillary sinus floor elevations grafted with OP-1 device, demineralized bone
matrix or autogenous bone. Comparison with non-grafted sites in a series of case
reports. Clin Oral Implants Res 1999;10:499-509.

24. Yildirim M, Spiekermann H, Biesterfeld S, Edelhoff D. Maxillary sinus

augmentation using xenogenic bone substitute material Bio-Oss in combination

66
 with venous blood. A histological and histomorphologic study in humans. Clin
Oral Implants Res 2000;11:217-229.

25. Schenk RK. Zur Problematik der Knochenersatzstoffe: Histophysiologie des

Knochenumbaus und der Substitution von Knochenersatzstoffen. In: Huggler
AH, Kuner EH (eds). Hefte zur Unfallheilkunde. Vol 216: Aktueller Stand beim
Knochenersatz. Berlin: Springer-Verlag, 1991:23-35.

26. Schlegel AK. Bio-Oss bone replacement materials. Long-term results with Bio-
Oss bone replacement material. Schweiz Monatsschr Zahnmed 1996;106:141-
149.

27. Schlegel AK, Donath K. Bio-Oss- A resorbable bone substitute? J Long-Term

Effects Med Implants 1998;8(3-4):201-209.

28. Skoglund A, Hising P, Young C. A clinical and histological examination in

humans of the osseous response to implanted natural bone mineral. Int J Oral
Maxillofac Implants 1997;12:194-199.

29. Klinge B, Alberius P, Isaksson S, Jönsson J. Osseous response to implanted

natural bone mineral and synthetic hydroxylapatite ceramic in the repair of
experimental skull bone defects. J Oral Maxillofac surg 1992;50:241-249.

30. Spector M. Anorganic bovine bone and ceramic analogs of bone mineral as
implants to facilitate bone regeneration. Clin Plast Surg 1994;21:437-444.

31. Berglundh T, Lindhe J. Healing around implants placed in bone defects treated
with Bio-Oss. An experimental study in the dog. Clin Oral Implants Res
1997;8:117-124.

32. Tadjoedin ES, De Lange GL, Holzmann PJ, Kuiper L, Burger EH. Histological
observations on biopsies harvested following sinus floor elevation using a

67
 bioactive glass material of narrow size range. Clin Oral Implants Res
2000;11:334-344.

33. Groeneveld HHJ, van der Bergh JPA, Holzmann P, ten Bruggenkate CM, Burger
EH. Bone formation after demineralized bone matrix implantation in sinus floor
elevations (abstract). Trans Europ Orthop Revs Soc 1998;8:48.

34. Parfitt AM, Drezner MK, Glorieux FH, et al. Bone histomorphometry:
Standardization of nomenclature, symbols, and units. Report of the ASBMR
Histomorphometry Nomenclature Committee. J Bone Miner Res 1987;2(6):595-
610.

35. Moy PK, Lundgren S, Holmes RE. Maxillary sinus augmentation:

Histomorphometrical analysis of graft materials for maxillary sinus floor
augmentation. J Oral Maxillofac Surg 1993;51:857-862.

36. Schlickewei W, Paul C. Experimentelle Untersuchung zum Knochenersatz mit

bovinem Apatit. In: Huggler AH, Juner EH (eds). Hefte zur Unfallheilkunde.
Vol 216: Aktueller Stand beim Knochenersatz. Berlin: Springer-Verlag,
1991:59-69.

37. Szabó G, Suba Z, Divinyi T, Haris A. HTR polymer and sinus elevation: A
human histological evaluation. J Long Term Effects Med Implants 1992;2:80-
92.

38. Valentini P, Abensur D, Densari D, Graziani JN, Hämmerle C. Histological

evaluation of Bio-Oss in a 2-stage sinus floor elevation and implantation
procedure: A human case report. Clin Oral Implants Res 1998;9:59-64.

39. Hrabák K, Szabó G, Ewers R, Gyulai-Gaál S. 2D and 3D computer tomography

and sinus graft analysis with various graft materials. J Long-Term Effects Med
Implants 1999;9(3):223-233.

68
40. Kent JN. Bone maintenance five to ten years after sinus bone grafting (abstract).
J Oral Maxillofac Surg 1997;55(8 suppl 3):92.

41. Luka B, Berchtelsbauer D, Gellrich NC, König M. 2D and 3D CT

reconstructions of the facial skeleton: An unnecessary option or a diagnostic
pearl? Int J Oral Maxillofac Surg 1995;24:76-80.

42. Misch CE. Density of bone: Effect on treatment plans, surgical approach,
healing, and progressive bone loading. Int J Oral Implantol 1990;6:23-31.

43. Ono J, Ohura T, Narumi E, et al. Three-dimensional analysis of craniofacial

bones using three-dimensional computer tomography. J Craniomaxillofac Surg
1992;20:49-60.

44. Rothman SLG. Dental Applications of Computerized Tomography: Surgical

Planning for Implant Placement. Chicago: Quintessence, 1998:142-152.

45. Schwartz MS, Rothman SLG, Chafetz N, Rhodes M. Computer tomography:

Part I, preoperative assessment of the mandible for endosseous implant surgery.
Int J Oral Maxillofac Implants 1987;2:137-141.

46. Schwartz MS, Rothman SLG, Chafetz N, Rhodes M. Computer tomography:

Part II, preoperative assessment of the maxilla for endosseous implant surgery.
Int J Oral Maxillofac Implants 1987;2:143-18.

47. Wicht L, Moegelin A, Schedel H, et al. Dental-CT Studie zur preoperativen

Beurteilung der Kieferatrophie. Aktuel Radiol 1994;4:64-81.

48. Gruber AJ. Practical applications of a bone substitute-Beta-tricalcium phosphate

in hand surgery. Trauma Line 1999;2:50-58.

69
49. Foitzik C, Staus H. Phasenreines β-Tricalcium Phosphat zum Knochenersatz bei
parodontaler Indikation. Quintessenz 1999;50:1049-1058.

50. Ghazal G, Prein J. Bone defect filling material in jaw bones using tricalcium
phosphate (in German). Swiss Dent 1992;13(1):15-18.

51. LeGeros RZ. Biodegradation and bioresorption of calcium phosphate ceramics.

Clin Mater 1993;14(1):65-88.

52. Rejda B, Peelen J, De Groot K. Tricalcium phosphate as a bone substitute. J

Bioeng 1977;1:93-101.

53. Reinhardt C, Kreusser B. Retrospective study of dental implantation with sinus

lift and Cerasorb augmentation. Dent Implantol 2000;4:18-26.

54. Reuger JM, Linhart M, Sommerfeldt D. Biologic reactions to calcium phosphate

ceramic implantations. Result of animal experiments. Orthopädie 1998;27:89-95.

55. Szucs A, Suba Z, Martonffy K, et al. The importance of the pure-phase β-

tricalcium phosphate (Cerasorb) in preprosthetic surgery (in Hungarian). Fogorv
Szle 2000;93:45-52.

56. Brånemark PI, Adell R, Breine U, Hansson BO, Lindström J, Ohlsson A. Intra-
osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast
Reconstr Surg. 1969;3:81.

57. Schroeder A, Pohler O, Sutter F. Gewebsreaktion auf ein Titan-

Hohlzylinderimplantat mit Titan-Spritzschichtoberfläche. Schweiz Monatsschr
Zahnheilk 1976;86: 713.

70
58. Schroeder A, Van der Zypen E, Stich H, Sutter F. The reaction of bone,
connective tissue and epithelium to endosteal implants with sprayed titanium
surfaces. J Maxillofac Surg 1981; 9:15.

59. Listgarten MA, Buser D, Steinemann S, Donath K, Lang NP, Weber HP. Light
and transmission electron microscopy of the intact interface between non-
submerged titanium-coated epoxy resin implants and bone or gingiva. J Dent
Res 1992;71:365.

60. Gotfredsen K, Rostrup E, Hjørting-Hansen E, Stoltze K, Budtz- Jörgensen E.

Histological and histomorphometrical evaluation of tissue reactions adjacent to
endosteal implants in monkeys. Clin Oral Impl Res 1991;2:30.

61. Brånemark P-I, Zarb GA, Albrektsson T (eds). Tissue-integrated Prostheses:

Osseintegration in Clinical Dentistry. Chicago: Quintessence, 1985.

62. Bergkvist G, Sahlholm S, Karlsson U, Nilner K, Lindh C. Immediately loaded

implants supporting fixed prostheses in the endentulous maxilla: A preliminary
clinical and radiologic report. Int J Oral Maxillofac Implants 2005;20:399-405.

63. Buser D, Belser UC, Lang NP. The original one-stage dental implant system and
its clinical application. Periodontol 2000 1998;17:106-118.

64. Bergkvist G, Sahlholm S, Nilner K, Lindh C. Implant-supported fixed prostheses

in the edentulous maxilla. A 2-years clinical and radiological follow-up of
treatment with non-submerged ITI implants. Clin Oral Implants Res
2004;15:351-359.

65. Ericsson I, Randow K, Nilner K, Peterson A. Early functional loading of

Bränemark dental implants: 5-year clinical follow-up study. Clin Implant Dent
Relat Res 2000;2:70-77.

71
66. Astrand P, Engquist B, Anzen B, et al. Nonsurmerged and sub-merged implants
in the treatment of the partially edentulous maxilla. Clin Implant Dent Relat Res
2002;4:115-127.

67. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage
1 surgery in edentulous arches: Ten consecutive case reports with 1-to 5-year
data. Int J Oral Maxillofac Implants 1997;12:319-324.

68. Balshi TJ, Wolfinger GJ. Immediate loading of Bränemark implants in

edentulous mandibles: A preliminary report. Implant Dent 1997;6:83-88.

69. Grunder U. Immediate functional loading of immediate implants in edentulous

arches: two-year results. Int J Periodontics Restorative Dent 2001;21:545-551.

70. Jaffin Ra, Kumar A, Berman CL. Immediate loading of implants in partially and
fully edentulous jaws: A series of 27 case reports. J Periodontol 2000;71:833-
838.

71. Van Steenberghe D, Naert I, Andersson M, Brajnovic I, Van Cleynenbreugel J,

Suetens P. A custom template and definitive prosthesis allowing immediate
implant loading in the maxilla: A clinical report: Int J Oral Maxillofac Implants
2002;17:663-670.

72. Berewal RM, Oates TW, Meredith N, Cochran DL. Resonance frequency
measument of implant stability in vivo on implants with a sandblasted and acid-
etched surface. Int J Oral Maxillofac Implants 2003;18:641-651.

73. Brunski JB. In vivo bone response to biomechanical loading at the bone/dental-
implant interface. Adv Dent Res 1999;13:99-119.

72
74. Adell R, Eriksson B, Lekholm U, Brånemark P-I, Jemt T. A long-term follow-up
study of osseointegrated implants in the treatment of totally edentulous jaws. Int
J Oral Maxillofac Implants 1990;5:347.

75. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated

implants. The Toronto study. Part I: Surgical results. J Prosthet Dent
1990;63:451.

76. Babbush CA, Kent JN, Misiek DJ. Titanium plasma-sprayed (TPS) screw
implants for the reconstruction of the edentulous mandible. J Oral Maxillofac
Surg 1986;44:274.

77. Ten Bruggenkate CM, Muller K, Oosterbeek HS. Clinical evaluation of the ITI
(F-type) hollow cylinder implant. Oral Surg Oral Med Oral Pathol 1990;70:693.

78. Krekeler G, Schilli W, Geiger H. Das TPS-Implantat, ein zuverlässiges

Retentionselement. Z Zahnärztl Implantol 1990;6:229.

79. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated

dental implants in anterior partially edentulous patients. Int J Prosthodont
1993;6:180.

80. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated

dental implants in posterior partially edentulous patients. Int J Prosthodont
1993;6:189.

81. Langer B, Langer L, Herrmann I, Jorneus L. The wide fixture: a solution for
special bone situatuons and a rescue for the compromised implant . Part 1. Int J
Oral Maxillofac Implants 1993;8:400.

82. Block MS, Kent JN, Kay JF. Evaluation of hydroxylapatite-coated titanium
dental implants in dogs. J Oral Maxillofac Surg 1987;45:601.

73
83. Keller EE, Van Roekel NB, Desjaedins RP, Tolman DE. Prosthetic-surgical
reconstruction of the severely resorbed maxillae with iliac bone grafting and
tisse integrated prostheses. Int J Oral Maxillofac Implants 1987;2:155.

84. Jensen J, Sindet-Pedersen S. Autogenous mandibular bone grafts and

osseointegrated implants for reconstruction of the severely atrophic maxilla: A
preliminary report. J Oral Maxillofac Surg 1991;49:1277.

85. Santoro F, Maiorana C. Osteointegrazione avanzata. RC Libri Srl Milano, 2001.

86. Szabó G. Oral and maxillofacial surgery. Semmelweis Publishing House.

Budapest, 2001.

87. Nentwig GH, Kniha H. Die Rekonstruktion lokaler Alveolarfotsatzrezessionen

im Frontzahnbereich mit Kalziumphosphatkeramik. Z Zahnärztl Implantol
1986;2:80.

88. Hurley LA, Stinchfield FE, Bassett ACL, Lyon WH. The role of soft tissues in
osteogenesis. J Bone Joint Surg 1959;41a:1243.

89. Bassett CAL, Creighton DK, Stinchfield FE. Contributions of endosteum, cortex
and soft tissues to osteogenesis. Surg Gynecol Obstet 1961;112:145.

90. Boyne PJ, Mikels TE. Restoration of alveolar ridges by intramandibular

transposition osseous grafting. J Oral Surg 1968;26:569.

91. Lazzara RJ. Immediate implant placement into extraction sites: Surgical and
restorative advantages. Int J Periodont Rest Dent 1989;9:333.

74
92. Nyman S, Lang NP, Buser D, Brägger U. Bone regeneration adjacent to titanium
dental implants using guided tissue regeneration: A report of two cases. Int J
Oral Maxillofac Implants 1990;5:9.

93. Becker W, Becker B. Guided tissue regeneration for implants placed into
extraction sockets and for implant dehiscences: Surgical techniques and case
reports. Int J Periodont Rest Dent 1990;10:377.

94. Jovanovic S, Spiekermann H, Richter EJ. Bone regeneration around titanium

dental implants in dehisced defect sites: A clinical study. Int J Oral Maxillofac
Implants 1992;7:233.

95. Nevins M, Mellonig J. Enhancement of the damanged edentulous ridge to

receive dental implants: A combination of allograft and the Gore-Tex
membrane. Int J Periodont Rest Dent 1992;12:97.

96. Itthagarun A, King NM. Ectodermal dysplasia: a review and case report.
Quintess Int 1997;28:595–602.

97. Bergendal T, Eckerdal O, Hallonsten AL, et al. Osseointegrated implants in the

oral rehabilitation of a boy with ectodermal dysplasia: a case report. Int Dent J
1991;41:149–56.

98. Paschos E, Huth KC, Hickel R. Clinical management of hypohidrotic ectodermal

dysplasia with anodontia: case report. J Clin Pediatr Dent 2002;27:5–8.

99. Franchi L, Branchi R, Tollaro I. Craniofacial changes following early prosthetic

treatment in a case of hypohidrotic ectodermal dysplasia with complete
anodontia. ASDC J Dent Child 1998;65:116–21.

75
100. Boyne PJ. Osseous reconstruction of the maxilla and the mandible: Surgical
techniques using titanium mesh and bone mineral. 1997 Quintessence
Publishing.

101. Boyne PJ. Maxillofacial surgery. Int Habal M (ed). Bone Grafts and Bone
Substitutes: Philadelphia: Saunders, 1992:291-298.

102. Burwell RG. Osteogenesis in cancellous bone grafts: Considered in terms of

cellular changes, basic mechanisms in the perspective of growth control, and
possible aberrations. Clin Orthop Related Res 1965;40:35-47.

103. Burwell RG. Studies in transplantation of bone. J Bone Joint Surg

1960;B,48:432-566.

104. Boyne PJ. Induction of bone repair of various bone graft materials. In: Sognnaes
RF (ed). Proceedings of the CIBA Foundation Symposium No: 11 on Hard
Tissue Growth, Repair, and Remineralization. Amsterdam: Elsevier Excerpta
Medica-North Holland, 1973:121-141.

105. Davarpanah M, Martínez H, Kebir M, Tecucianu. Clinical manual of implant

dentistry 2003 Quintessence Publishing Co.

106. Jensen J, Krantz Simonsen E, Sindet-Pedersen S. Reconstruction of the severely

resorbed maxilla with bone grafting and osseointegrated implants: A preliminary
report: J Oral Maxillofac Surg 1990;48:27-32.

107. Keller EE. Reconstruction of the severely atrophic edentulous mandible with
endosseous implants: A 10-year longitudinal study. J Oral Maxillofac Surg
1995:53:305-320.

108. Lindstrom J, Bränemark P-I, Albrektsson T. Mandibular reconstruction using the

performed autologous bone graft. J Plast Reconstr Surg 1981;15:29-36.

76
109. Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary
alveolar defects with mandibular symphysis grafts for dental implants. Int J Oral
Maxillofac Implants 1992;7:360-366.

110. Wesseling KH, Neukamm FW, Scheller H, et al. Clinical aspects of

osseointegrated implants in the extremely resorbed edentulous lower and upper
jaw. Z Zahnarztl Implantol 1992;7:51-55.

111. Antoun H, Misch C, Diestsh F, Feghali M. Augmentation de crête par greffe

osseuse prélevée à la symphyse mentonnière. J Parodontol Implant Orale
1995;14:285-294.

112. Horch HH, Sader R, Kolk A: Synthetische, phasenreine Beta-

Tricalciumphosphat-Keramik (Cerasorb) zur Knochenregeneration bei der
rekonstruktiven Chirurgie der Kiefer-Eine lklinische Langzeitstudie mit
Literaturübersicht. Deutsche Zahnärztliche Zeitscrift 2004,12:680-686.

113. Jäger M, Westholf B, Wild A, Krauspe R: Knochenspanentnahme am Becken –

Techniken und Probleme: Der Orthopäde, Springer online publ., 02. August
2005.

114. Jerosch J, Bader A, Uhr G: Knochen curasan Taschenatias spezial. Thieme,

Stuttgart, New York 2002.

115. McAllister BS, Margolin MD, Cogan AG, Buck D, Hollinger JO, Lynch SE.
Eighteen-month radiographic and histologic evaluation of sinus grafting with
anorganic bovine bone in the chimpanzee. Int J Oral Maxillofac Implants 1999;
14:361-368.

77
116. Valentini P, Abensur DJ, Maxillary sinus grafting with anorganic bovine bone:
A clinical report of long-term results. Int J Oral Maxillofac Implants
2003;18:556-560.

117. Donath K. Integration of bone substitutes in the jawbone. Morphologic findings

(in German). Dtsch Zahnärztl Z 1988;43:16-21.

118. Richter HE, Surg WE, Boyne PJ. Stimulation of osteogenesis in the dog
mandible by autogenous bone marrow transplants. Oral Surg, Oral Med, and
Oral Path 1968;26(3):369-405.

119. Wozney JM, Rosen V, Celeste AJ, Mitsock LM, Whitters MJ, Kriz RW, Hewick
RM, Wang EA. Novel regulators of bone formation: Molecualr clones and
activities. Science 1988;242:1528-1534.

120. Simion M, Baldoni M, Rossi P, et al.A comparative study of the effectiveness of

e-PTFE membrenes with and without early exposure during the healing period .
Int J Periodontal Rest Dent 1994;14:167–80.

121. Simion M, Misitano U, Gionso L, et al. Treatment of dehiscences and

fenestrations around dental implants using a resorbable and non-resorbable
membranes associated with bone autografts: A comparative clinical study. Int J
Oral Maxillofac Impl 1997;12:159–67.

122. Zitzmann N, Naef R, Schärer A. Resorbable versus non-resorbable membranes

in combination with Bio-Oss for guided bone regeneration. Int J Maxillofac Impl
1997;12: 844–52.

123. Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration around titanium
dental implants in dehisced defect sites: a clinical study. Int J Oral Maxillofac
Impl 1992;7:233–45.

78
124. Lundgren D, Sennerby L, Falk H, et al. The use of new bioabsorbable barrier for
guided bone regeneration in connection with implant installation. Case reports.
Clin Oral Impl Res 1994;5:177–84.

125. Mayfield L, Nobrèus N, Attström R, et al. Guided bone regeneration in dental

implant treatment using a bioabsorbable membrane. Clin Oral Impl Res
1997;8:10–17.

126. Mayfield L, Skoglund A, Nobréus N, et al. Clinical and radiographic evaluation,

following delivery of fixed reconstructions, at GBR treated titanium fixtures.
Clin Oral Impl Res 1998;9:292–302.

127. Boyne PJ. Vergleich V. Bio-Oss und anderen Implantationsmaterialien bei der
Erhaltung des Alveolarkammes des Unterkiefers beim Menschen.
Unfallheikunde 1991;216:98-103.

128. Cawood JI, Howell A. Reconstructive preprosthetic surgery. I. Anatomical

considerations. Int J Oral Maxillofac Surg 1991;20:75-82.

129. Wippermann BW, Schratt H-E, Steeg S, Tscherne H. Komplikationen der

Spongiosaentnahme am Beckenkamm. Eine retrospektive Analyse von 1191
Fällen. Chirurg 1991(68),1286-1291.

130. Tatum H Jr. Maxillary and sinus implant reconstruction. Dent Clin N Am
1986;30:207-229.

131. Parfitt AM, Drezner MK, Glorieux FH, et al. Bone histomorphometry:
standardization of nomenclature, symbols, and units. Report of the ASBMR
Histomorphometry Nomenclature Committee. J Bone Miner Res 1987;2:6:595-
610.

79
132. Schulte W, Lukas D. Periotest to monitor osseointegration and to check the
occlusion in oral implantology. J Oral Implantol 1993;19:23–32.

133. Szabó G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabás J, Németh Z,

Hrabák K, Suba Z. A prospective multicenter randomized β-Tricalcium
phosphate graft alone for bilateral sinus elevation: histologic and
histomorphometric evaluation.Int J Oral Maxillofac Implants 2005;20:371-381.

134. St John Ta. Vaccaro AR, Sah AP, Schaefer M, Berta SC, Albert T, Hilibrand A.
Physical and monetary costs associated with autogenous bone graft harvesting.
Am J Orthpo 2003 Jan;32(1):18-23.

135. Banwart JC, Asher MA, Hassenein Rs. Illiac crest bone graft harvest donor site
morbidity. A statistical evaluation. Spine 1995 May 1:20(9):1055-60.

136. Hauschild G, Bader A. Vor- und Nachteile synthetischer versus xenogener

Knochenersatzmaterialien. Tierärztliche Praxis Kleintiere 2004;32:67-70.

137. Hoenig JF, Merten HA, Heinemann DE. Risk of transmission of agents
associated with Creutzfeldt-Jaob disease and bovine spongiform encephalopathy.
Plast Reconstr Surg 1999 Apr;103(3):1324-5.

138. Hille R. Alveolar Ridge Preservation: Knochenaufbau nach Extraktion,

Implantologie Journal 2005;1:12-18.

139. Joshi A, Kostakis GC. An investigation of post-operative morbidity following

iliac crest graft harvesting. Br Dent J 2004 Feb 14;196(3):167-71.

140. Szabò G, Barabás J, Hrabák K, Suba Zs, U. Garagiola, B. Kádár Autologer

knochen versus ß-tricalcium phosphat allein eine radiologische und
histologische evaluation.
Z Oral Implantologie 2005(4): 2-8.

80
141. Merten Ha, Gruber RM, Nitsch A, Ludwing A, Schliephake H. Evaluation
oralchirurgischer Augmentationsmaterialien – Ein tierexperimentell-
histomorphologischer Vergleich. Implantologie 2003;11/3,215-236.

142. Neukam FW, Buser D. Implantate bei unzureichendem Knochenangebot. In:

Koeck B, Wagner W, eds. Implantologie. 1. Ed. München, Wien, Baltimore:
Urban & Schwarzenberg, 1996;177-218.

143. Wenz B, Ackermann K-L. Ist die Sinusbodenaugmentation mit

Knochenersatzmaterial erfolgreich durchführbar? Dent Implantol 2003(7), 376-
385.

144. Yildirim M, Spiekermann H, Handt S, Edelhoff D. Maxillary sinus augmentation

with the xenograft Bio-Oss and autogenous intraoral bone for qualitative
improvement of the implant site: A histologic and histomorphometric clinical
study in humans. Int J Oral Maxillofac Implants 2001;16:23-33.

145. Yildirim M. Präimplantologische Knochenregeneration unter besonderer

Berücksichtigung der Verwendung von Knochenersatzmaterialien: Ergebnisse
experimenteller und klinischer Untersuchungen. 2002 Habilitationsschrift,
Med.Fak. Aachen.

146. Wallace SS, Froum SJ. Effect of Maxillary sinus augmentation on the survival of
endosseous dental implants. A systematic review. Ann Periodontol 2003;8:328-
343.

147. Schmelzeisen R, Schimming R, Sittinger M. Making bone: Implant insertion

into tissue-engineered bone for maxillary sinus floor augmentation- A
preliminary report. J Craniomaxillofac Surg 2003;31-49.

81
148. Niedhart C, Pingsmann A, Jürgens C, Marr A, Elatt R, Niethard FU.
Complications after harvesting of autologous bone from the ventral and dorsal
iliac crest- A prospective, controlled study (in German). Z Orthop Ihre Grenzgeb
2003;141:481-486.

149. Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC. Histologic and clinical
of bilateral sinus floor elevations with and without barrier membrane placement
in 12 patients: Part 4 of an ongoing prospective study. Int J Periodontics
Restorative Dent 2000;20:117-125.

150. Suba Z, Hrabák K, Huys L, Coulthard P, Maiorana C, Garagiola U, Szabó G.A

ß-trikalcium-foszfát graft csontregeneráló hatásának hisztológiai és
hisztomorfometriai vizsgálata (multicentrikus tanulmány).
Orv Hetil 2004:145:1431-1437. Hungarian

151. Skoglund A, Hising P, Young C. A clinical and histological examination in

humans of the osseous response to implanted natural bone mineral. Int J Oral
Maxillofac Implants 1997;12:194-199.

152. Guckes AD, Brahim JS, McCarthy GR, et al. Using endosseous dental implants
for patients with ectodermal dysplasia. J Am Dent Assoc 1991;122:59–62.

153. Guckes AD, Scurria MS, King TS, et al. Prospective clinical trial of dental
implants in persons with ectodermal dysplasia. J Prosthet Dent 2002;88:21–5.

154. Escobar V, Epker BN. Alveolar bone growth in response to endosteal implants in
two patients with ectodermal dysplasia. Int J Oral Maxillofac Surg 1998;27:445–
7.

155. Kearns G, Sharma A, Perrott D, et al. Placement of endosseous implants in

children and adolescents with hereditary ectodermal dysplasia. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1999;88:5–10.

82
156. Westwood RM, Duncan JM. Implants in adolescents: a literature review and case
reports. Int J Oral Maxillofac Impl 1996;11:750–5.

157. Simion M, Scarano A, Gionso L, et al. Guided bone regeneration using

resorbable and non-resorbable membranes: A comparative histologic study in
humans. Int J Oral Maxillofac Impl 1996;11:735–42.

158. Itthagarun A, King NM. Oral rehabilitation of a hypohidrotic ectodermal

dysplasia patient: a 6-year follow-up. Quintess Int 2000;31:642–8.

159. Bergendal B. Prosthetic rehabilitation of a young patient with hypohidrotic

ectodermal dysplasia and oligodontia: a case report of 20 years of treatment. Int
J Prosthodont 2001;14:471–9.

160. Bonin B, Saffarzadeh A, Picard A, et al. Early implant treatment of a child with
anhidrotic ectodermal dysplasia. A proposal of a case. Rev Stomatol Chir
Maxillofac 2001;102:313–8.

161. National Foundation for Ectodermal Dysplasias. A dental guide to the

ectodermal dysplasia. NFED 1999.

162. Garagiola U, Maiorana C, Ghiglione V, Marzo G, Santoro F, Szabò G.

Osseointegration and guided bone regeneration in Ectodermal Dysplasia
patients. J Craniofacial Surg 2006;17(6) (in press)

Notes
Figures 9.: Taken from Szabó G. Oral and maxillofac surgery. Semmelweis Publishing House. Budapest, 2001.
Figures 10.: Taken from National Foundation for Ectodermal Dysplasias. A dental guide to the Ectodermal Dysplasia. NFED 1999.
Figures 8., 17., 18., 19., 22.: Taken from Santoro F, Maiorana C. Osteointegrazione avanzata. RC Libri Srl Milano, 2001.

83
12. – LIST OF AUTHOR’S PUBLICATIONS

12.1 – LIST OF PUBLICATIONS CONNECTED WITH THE TOPIC

1. Garagiola U, Maiorana C, Ghiglione V, Marzo G, Santoro F, Szabò G.

Osseointegration and guide bone regeneration in Ectodermal Dysplasia patients.
J Craniofac Surg 2006;17(6) (in press) IF: 1.017

2. Mortellaro C, Rimondini L, Farronato G, Garagiola U, Vercellino V, Berrone

M. Temporomandibular disorders due to improper surgical treatment of
mandibular fracture: Clinical Report.
J Craniofac Surg 2006:17(2):373-382. IF: 1.017

3. Mortellaro C, Garagiola U, Greco Lucchina A, Grivetto F, Milone G,

Pappalardo S, Palmieri A, Scorsone D, Sammartino G. The use of silicon
elastomer in maxillofacial rehabilitation as a substitute for or in conjunction with
resins.
J Craniofac Surg 2006:17(1):152-162. IF: 1.017

4. Szabò G, Barabás J, Hrabák K, Suba Zs, U. Garagiola, B. Kádár Autologer

knochen versus ß-tricalcium phosphat allein eine radiologische und
histologische evaluation.
Z Oral Implantologie 2005(4): 2-8.

5. Szabò G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabás J, Németh Z,

Hrabák K, Suba Z. A prospective multicenter randomized clinical trial of
autogenous bone versus ß-tricalcium phosphate graft alone for bilateral sinus
elevation: histologic and histomorphometric evaluation.
Int J Oral Maxillofac Impl 2005:20(3):371-381. IF: 1.772

6. Mortellaro C, Garagiola U, Carbone V, Cerutti F, Marci V, Foglio Bonda PL.

Unusual oral manifestations and evolution in glycogen storage disease type 1b.

84
 J Craniofac Surg 2005:16(1):45-53. IF: 1.017

7. Suba Z, Hrabák K, Huys L, Coulthard P, Maiorana C, Garagiola U, Szabó G.A

ß-trikalcium-foszfát graft csontregeneráló hatásának hisztológiai és
hisztomorfometriai vizsgálata (multicentrikus tanulmány).
Orv Hetil 2004:145:1431-1437. Hungarian

8. Garagiola U, Gioventù S, Ghiglione V. Silver-Russell Syndrome.

Doctor Os 2003:Sep;14(7):721 – 726. Italian

9. Garagiola U. Orthognathic surgery, osseointegration and adult orthodontics:

multidisciplinary synergy to correct dentofacial deformities.
J Japan Ass Adult Orthod 2003:10(1):17-26. Japanese

10. Garagiola U. Interdisciplinary synergy to ensure best long-term outcomes:

osseointegration- orthodontics.
Pravissimo Journal 2002:Mar;4:16-19. English

11. Garagiola U, Nishiyama K, Eisenmann E. Aesthetics and function in the

production of posterior crowns on single implants: the Ankylos Balance system.
Quintessenza Odontotecnica 2002:Mar;19(3):208-219. Italian

12. Garagiola U, Santoro E, Ghiglione V. Oral and cranio-facial manifestations in

Axenfeld-Rieger Syndrome.
Mondo Ortodont 2001:Sep-Oct;26(5):369-383. Italian

13. Ghiglione V, Garagiola U, Cangiano A, Redemagni M. Uprighting of

mesioinclined molars using the NiTi-SE steel spring.
Mondo Ortodont 1999:May-Jun;24(3)165-176. Italian

14. Ghiglione V, Garagiola U, Folegatti P. Combined orthognathodontic–

implantologic treatment in patients affected with Ectodermal Dysplasia.

85
 Implant Oral 1998:Oct;1(4 ):23-30. Italian

15. Ghiglione V, Garagiola U, Maspero C. Orthodontic-osseointegration: an

interdisciplinary approach in a dental agenisis case.
Mondo Ortodont 1997:Nov-Dec;22(6 ):553-558. Italian

16. Santoro F, Ghiglione V, Garagiola U, Maiorana C. An orthodontic-surgical

approach for the diagnosis and treatment of class III open-bite.
Electromyographic and Kinesiographic evaluation. Description of two clinical
cases.
Ortognatodonzia Italiana 1996:5(6):811-823. Italian

86
12.2 – LIST OF PUBLICATIONS NON CONNECTED WITH THE TOPIC

1. Farronato G, Garagiola U, Farronato D, Bolzoni L, Parazzoli E. Temporary lip

paresthesia during orthodontic molar distalization: a case report.
Am J Orthod Dentofacial Orthop 2006 (in press) IF: 0.916

2. Farronato G, Garagiola U, Ghiglione U, Farronato D, Gioventù S, Selicorni A.

Moebius syndrome: a case report.
Quintessence Int 2006 (in press) IF: 0.540

3. Mortellaro C, Garagiola U, Torchio R, Gulotta G, Foglio Bonda PL, Farronato

G. Upper airway obstruction and orofacial deformity: an evaluation using the
whole body plethysmography technique.
Ear Nose & Throat Journal 2006 (in press)

4. Garagiola U, Vedani L, Ghiglione V. The Nd-YAG laser in orthognathodontics:

clinical considerations and biocompatibility. Part 1.
ORTEC 2001:2:7-18. Italian

5. Ghiglione V, Garagiola U. Electrokinesiographic evaluations of the skeletal

open-bite surgical treatment.
Medimond 2005:169-173. Italian

6. Garagiola U, Vedani L, Ghiglione V. The Nd-YAG laser in orthognathodontics:

clinical considerations and biocompatibility. Part 2.
ORTEC 2001:3:7-14 Italian

7. Garagiola U, Santoro E. Parodontal prevention in orthodontic treatment of child

and adolescent patient.
Professione Odontoiatria 2001: Jan;1:9-13. Italian

87
8. Garagiola U, Costanza C, Cocuzza L, Ghiglione V. Orthodontics-prosthesis
interdisciplinary techniques in the use of the Maryland Bridge.
Doctor OS 2000:Apr;11(4):357-362. Italian

9. Garagiola U, Ghiglione V. Parodontal prevention in adult orthognathodontic

patients.
Professione Odontoiatra – Suppl Doctor OS 2000:5:7-10. Italian

10. Ghiglione V, Garagiola U, Addamiano G, Addamiano F. Selective molar

intrusion by means of a double cantilever system.
Doctor OS 2000:May;11(5): 509-517. Italian

11. Ghiglione V, Garagiola U, Addamiano F, Cangiano A. Role of the stabilometric

board in orthognathodontics.
Attual Dental 1999:Sep;6(7):6-25. Italian

12. Ghiglione V, Maspero C, Garagiola U, Cocuzza L. The correlation between the

skeletal vertical dimension and the neuro-muscular system. A clinical case.
Attual Dental 1999:Feb;6(2): 14-26. Italian

13. Garagiola U, Zucchi P, Ghiglione V. Frankel’s functional regulator.

Attual Dental 1998: Sep; 5(7): 6-22. Italian

14. Ghiglione V, Garagiola U, Persia M. The role of the activator in interceptive

treatment of class II skeletal malocclusions.
Doctor OS 1998: Feb;9(2):19-26. Italian

15. Ghiglione V, Garagiola U. Handbook of Periodontics.

Ariesdue; Como; 1998:1-9. Italian

16. Ghiglione V, Garagiola U. Handbook of Oral Hygiene.

Ariesdue; Como; 1997:1-12. Italian

88
17. Ghiglione V, Goggi P, Garagiola U. Combined therapy by rapid palatal
expander - Delaire mask in early correction of skeletal class III.
Mondo Ortod 1997:May – Jun; 23(3):235-242. Italian

18. Ghiglione V, Garagiola U, Mori P. Role of Electromyographic investigation in

orthognathodontic diagnosis and treatment.
Doctor OS 1995: Jun – Jul;6(6):54-63. Italian

19. Ghiglione V, Garagiola U, Frisoni A. Role of the Ginevra type monoblock in

interceptive therapy: discussion of a clinical case.
Mondo Ortod 1995: Apr;20(2):373-378. Italian

20. Maiorana C, Garagiola U, Santoro F. Neuromuscular system and the Rolfing

method in craniomandibular disorders.
Mondo Ortod 1992: July - Aug;17(4):369-375. Italian

89
13. - LIST OF AUTHOR’S ABSTRACTS

13. 1 - LIST OF ABSTRACTS CONNECTED WITH THE TOPIC

1. Garagiola U., Toia M., Arnaboldi O., Santoro G.

Osseointegration and bone regeneration in patients affected by Ectodermal
Dysplasia.
15th Annual Meeting of the European Association for Osseointegration; Zurich,
Switzerland, 2006.

2. Garagiola U., Maiorana C., Santoro F., Szabò G.

Osseointegration and bone reconstruction in patients affected by Ectodermal
Dysplasia.
XVIII Congress of the European Association for Cranio-Maxillofacial Surgery;
Barcelona, Spain, 2006.

3. Garagiola U. Nishiyama K., Szabò G.

Timing and effects of orthodontic loading on mini-implants for skeletal

anchorage .
106th Congress of the American Association of Orthodontists; Las Vegas, USA,
2006.

4. Garagiola U., Ghiglione V.

Dentofacial deformities in adult patient: Multidisciplinary surgical-orthodontic
treatment.
7° Congresso Nazionale di Medicina Estetica; Milan, Italy, 2005.

5. Garagiola U., Szabò G., Santoro F.

Occlusal overload as primary risk factor of prosthetic implant failures.
14th Annual Scientific Meeting of the European Association for
Osseointegration; Munich, Germany, 2005.

90
 Clin Oral Implants Res 2005:16(4):402. IF: 1.897

6. Garagiola U., Nishiyama K., Szabò G.

Skeletal anchorage for tooth movements: mini implants vs osseointegrated
implants.
6th International Orthodontics Congress; Paris, France, 2005.
World Journal of Orthodontics 2005:6(Suppl):117.

7. Garagiola U., Szabò G., Santoro E.

Osseointegrated implants use in craniomandibular disorder patients: implant
overload prevention.
17th International Conference on Oral & Maxillofacial Surgery; Vienna, Austria,
2005.
Int J Oral Maxillofac Surg 2005: Aug;34(1):19. IF: 1.123

8. Garagiola U., Ghiglione V., Farronato G.

Potential risk of periodontal breakdown during surgical-orthodontic therapy.
81st European Orthodontic Society Congress; Amsterdam, The Netherlands,
2005.

9. Garagiola U., Santoro F., Ghiglione V., Farronato G.

Potential periodontal consequences during orthodontic tooth movement in
orthognathic surgery.
105th Congress of the American Association of Orthodontists; San Francisco,
USA, 2005.

10. Ghiglione V., Garagiola U., Santoro F.

Class III malocclusion and vertical dimension: interceptive orthodontics or
orthognatic surgery?

XIX Congresso Nazionale SIDO; Rimini, Italy, 2005.

11. Garagiola U., Szabò G., Santoro F., Spadari F.

91
 Early detection and multidisciplinary management of Gorlin-Goltz syndrome:
the dentists’role.
10th International Congress on Oral Cancer, Island of Crete, Greece, 2005.
Oral Oncology 2005:Apr;1(1):140. (Suppl) IF: 2.266

12. Garagiola U., Szabò G., Santoro F.

Potential risk factors of implant use in temporomandibular disorders patients.
83rd General Session & Exhibition of the IADR/AADR/CADR; Baltimore, USA,
2005.
J Dent Res 2004:84:Special Issue A. (Cd-Rom) IF: 3.192

13. Garagiola U., Laskin DM., Santoro F.

Potential risk factors for implant failure in temporomandibular disorders
patients.
4th World Congress of Osseointegration; Venice, Italy, 2004.
Italian J Osseointegration 2004: May-Aug;4(2):64.

14. Garagiola U., Ghiglione V.

Videocephalometric prediction of facial aesthetic changes in orthognathic
surgery and psyche.
6th Congresso Nazionale di Medicina Estetica; Milan, Italy, 2004.

15. Garagiola U., Santoro F., Szabo’ G.

Stability and relapse after surgical-orthodontic correction of skeletal open-bite
deformities.
XVII Congress of the European Association for Cranio-Maxillofacial Surgery;
Tours, France, 2004.
J Cranio Maxillofac Surg 2004: Sep;32(1):148. IF: 0.991

16. Garagiola U., Santoro E., Bodin C., Laskin DM.

Potential success and risk factors for implant use in temporomandibular
disorders patients.

92
 XVIIth Congress of the European Association for Cranio-Maxillofacial Surgery;
Tours, France, 2004.
Journal Cranio Maxillofac Surg 2004: Sep;32(1):311. IF: 0.991

17. Foglio Bonda P.L., Garagiola U., Rocchetti V.

In vitro corrosion resistance of titanium in fluorinated environment.
13th European Association for Osseintegration ; Paris, France, 2004.
Clin Oral Implants Res 2004: Aug;15(4):43. IF: 2.139

18. Garagiola U., Santoro F., Szabo’ G.

Gorlin-Goltz Syndrome: early detection and multidisciplinary management.
7th Congress of the European Academy of Paediatric Dentistry; Barcelona,
Spain, 2004.
European J Paediatric Dentristry 2004:Sep;5:59.

19. Garagiola U., Ghiglione V., Farronato G.

Orthognathic surgery and temporomandibular joint disorders: functional and
neuromuscular evaluation.
80th European Orthodontic Society Congress; Aarhus, Denmark, 2004.

20. Garagiola U., Santoro F.

Predictability and stability of orofacial deformities correct by orthognathic
surgery
5th International Danubius Conference on Oral and Maxillofacial Surgery; 8th
Congress of the Hungarian Association of Oral and Maxillofacial Surgeons;
Budapest, Hungary, 2004.

21. Garagiola U., Gioventù S., Ghiglione V., Farronato G.

Odontostomatological aspects of Silver-Russell Syndrome.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, La
Prevenzione e La Sicurezza per il Professionista e l’Utenza in Odontoiatria;
Rome, Italy, 2004.

93
22. Garagiola U., Foglio Bonda P.L., Dall’Oca S., Migliario M., Rocchetti V.
Antihemorrhage preventive treatment in dental patients suffering from
coagulopathy.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, La
Prevenzione e La Sicurezza per il Professionista e l’Utenza in Odontoiatria;
Rome, Italy, 2004.

23. Garagiola U., Gioventù S., Ghiglione V., Farronato G.

Early and delayed loads in orthodontic skeletal anchorage through the use of
mini-implants.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, La
Prevenzione e La Sicurezza per il Professionista e l’Utenza in Odontoiatria;
Rome, Italy, 2004.

24. Garagiola U., Mortellaro C., Migliario M., Scorsone D., Pappalardo S.
Indications and contraindications of the surgical treatment of impacted teeth in
adults.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, La
Prevenzione e La Sicurezza per il Professionista e l’Utenza in Odontoiatria;
Rome, Italy, 2004.

25. Garagiola U., Mortellaro C., Carbone V., Bello L., Pappalardo S.
Craniomandibular disorders after surgical treatment of mandibular fracture
consolidated in wrong position.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, La
Prevenzione e La Sicurezza per il Professionista e l’Utenza in Odontoiatria;
Rome, Italy, 2004.

26. Garagiola U., Ghiglione V.

Treatment of serious dento-facial aesthetic problems: multidisciplinary synergy.

94
 XIV International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 2003.

27. Garagiola U., Ghiglione V.

Implantology and orthodontics in the synergic interdisciplinary correction of
dento-facial aesthetics.
5th Congresso Nazionale di Medicina Estetica; Milan, Italy, 2003.

28. Garagiola U., Nishiyama K., Santoro F.

Orthodontic skeletal anchorage in complex cases: mini-implants vs
osteointegrated fixtures.
91 FDI Annual World Dental Congress; Sydney, Australia, 2003.

29. Garagiola U., Spadari F., Foglio Bonda P.L.

Early detection and management of Gorlin-Goltz Syndrome : the dentists’ role.
91 FDI Annual World Dental Congress; Sydney, Australia, 2003.

30. U. Garagiola
Implant prosthodontics timing, loading and management in Ectodermal
Dysplasia patients.
6 ème Symposium Sociètè Internationale de Prothèse Adjointe Fonctionelle
(SIPAF) - Annual Meeting 2003 American Academy of Implant Prosthodontics
(AAIP); France, 2003.

31. Garagiola U., Ghiglione V., Nishiyama K.

Timing, loading and placement of mini-implants and implants as orthodontic
anchorage.
79th Congress of the European Orthodontic Society; Prague, 2003.
Eur J Orthod 2003: Aug;25(4):430-431. IF: 0.656

32. Garagiola U., Ghiglione V., Farronato G.

Effects of bimaxillary surgery on the mid and lower facial soft tissues.

95
 79th Congress of the European Orthodontic Society; Prague, 2003.

33. Garagiola U., Farronato G., Re E.

Early detection and management of Gorlin-Goltz Syndrome – The orthodontist’s
role.
79th Congress of the European Orthodontic Society; Prague, 2003.

34. Garagiola U., Re E., Farronato G.

Ectodermal Dysplasia: Multidisciplinary Synergy.
79th Congress of the European Orthodontic Society; Prague, 2003.

35. Garagiola U., Ghiglione V., Cressoni P., Re E., Spadari F.

Odontostomatological manifestations of Gorlin-Goltz syndrome.
10th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Tecnologie
Avanzate in Odontoiatria; Rome, Italy, 2003.

36. Garagiola U., Fusco M., Farronato G., Maiorana C.

Orthodontic skeletal anchorage by the means of osseointegrated implants and
mini-implants.
10th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Tecnologie
Avanzate in Odontoiatria; Rome, Italy, 2003.

37. Garagiola U., Spadari F., Re E., Fusco M., Farronato G.

Relapse and stability of skeletal open-bite corrected by means of bimaxillary
surgery.
10th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Tecnologie
Avanzate in Odontoiatria; Rome, Italy, 2003.

38. Garagiola U., Ghiglione V., Re E., Maiorana C.

Peri-implant bone resorption following the supracrestal positioning of the
implant collar.

96
 10th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Tecnologie
Avanzate in Odontoiatria; Rome, Italy, 2003.

39. Nishiyama K., Garagiola U.

Harmonic aesthetics and function in implantology: clinical evaluations in
posterior partially edentolous patients.
XIV International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 2002.

40. Garagiola U., Ghiglione V., Nishiyama K.

Osseointegration-orthodontics: interdisciplinary treatment in patients with
Ectodermal Dysplasia.
6° European Academy of Paediatric Dentistry; Dublino, Ireland, 2002.
J Eur Academy of Paediatric Dentistry; 2002: Sep;3:142.

41. U. Garagiola
Implantology, Orthodontics, Orthognathic Surgery: An interdisciplinary
approach to managing complex treatment plans.
5th International Implant Dentistry Meeting; Cologne, Germany, 2002.

42. Garagiola U., Ghiglione V., Farronato G.

Skeletal orthodontic anchorage: mini-implants compared to osseointegrated
implants.
XVII Convegno Nazionale SIDO; Florence, Italy, 2002.

43. Garagiola U., Ghiglione V., Farronato G.

Stability and relapse in dysgnathia corrected by means of orthognathic surgery.
XVII Convegno Nazionale SIDO; Florence, Italy, 2002.

44. Garagiola U., Ghiglione V.

Genioplasty in combination with orthognathic surgery for the correction of
orofacial deformities.

97
 4th Congresso Nazionale di Medicina Estetica; Medicina di Prevenzione ed
Orientamenti Terapeutici; Milan, Italy, 2002.

45. Farronato G., Bellintani C., Garagiola U.

Facial asymmetry: diagnostic protocol and therapeutic indications.
4th Congresso Nazionale di Medicina Estetica; Medicina di Prevenzione ed
Orientamenti Terapeutici; Milan, Italy, 2002.

46. Garagiola U., Ghiglione V., Nishiyama K.

Skeletal anchorage for tooth movements: mini-implants vs. osseointegrated
implants.
11th European Association for Osseointegration; Brussels, Belgium, 2002.
Clin Oral Implants Res 2002: Aug;13(4) :36. IF: 1.503

47. U. Garagiola
Orthognathic surgery, osseointegration and adult orthodontics: multidisciplinary
synergy to correct dentofacial deformities.
1st International Congress of Japan Association of Adult Orthodontics; Tokyo,
Japan, 2002.
Japan Ass Adult Orthod 2002:102-103.

48. Garagiola U., Ghiglione V., Santoro E.

Stability and relapse of dentofacial disharmonies after orthognathic surgery.

78th Congress of the European Orthodontic Society; Sorrento, Italy, 2002.

49. Garagiola U., Ghiglione V., Nishiyama K.

Orthodontic skeletal anchorage: mini-implants versus osseointegrated implants.

78th Congress of the European Orthodontic Society; Sorrento, Italy, 2002.

50. Garagiola U., Re E., Motta B., Ghiglione V.

Facial tissue profile and aesthetic appearance after bimaxillary surgery.

98
 Convegno Internazionale sull’Estetica Orale e Facciale: Armonia tra forma e
funzione: la costante ricerca dell’estetica in odontoiatria, Milan, Italy, 2002.

51. Garagiola U., Fusco M., Re E., Ghiglione V.

Multidisciplinary synergy in the correction of deformities and dento-facial
beauty problems.
9th Congresso Nazionale del Collegio dei Docenti; L’Odontoiatria del Terzo
Millennio; Rome, Italy, 2002.

52. Garagiola U., Santoro E., Cressoni P., Ghiglione V.

Videocephalometric prediction of the effects of orthognathic surgery on the soft
tissues of the face.

9th Congresso Nazionale del Collegio dei Docenti; L’Odontoiatria del Terzo
Millennio; Rome, Italy, 2002.

53. Garagiola U., Ghiglione V., Nishiyama K.

Peri-implant bone levels after supracrestal implant collar placement in
submerged implants.
17th Annual Meeting of the Academy of Osseointegration; Dallas, USA, 2002.

54. Nishiyama K., Garagiola U.

Clinical evaluation of the use of mini-implants as skeletal orthodontic
anchorage.
XIII International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 2001.

55. Garagiola U., Santoro E., Paini L., Ghiglione V.

Effects of bimaxillary orthognathic surgery on facial soft tissue profile.
XIII International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 2001.

56. Garagiola U.

99
 Interdisciplinary synergy osseointegration-orthodontics to ensure the best long-
term outcomes. 4th International Implant Dentistry Meeting; Hanover, Germany,
2001.

57. Garagiola U., Cressoni P., Gualano M.G., Ghiglione V.

Genioplasty in association with orthognathic surgery in serious facial
deformities.

XVI Congresso Nazionale SIDO; Genoa, Italy, 2001.

58. Garagiola U., Ghiglione V., Bellintani C.

Multidisciplinary synergy in the treatment of serious dento-facial deformities.
3rd Congresso Nazionale di Medicina Estetica; Milan, Italy, 2001.

59. Garagiola U., Santoro E., Nishiyama K.

Orofacial deformities requiring genioplasty associated with orthognathic surgery
in both jaws.

89th FDI Annual World Dental Congress, Kuala Lumpur, Malaysia, 2001.
Int Dental J 2001:Oct51(5):368. IF: 0.713

60. Garagiola U., Ghiglione V., Nishiyama K.

Supracrestal implant collar placement vs short fixtures in submerged implants.
10th European Association for Osseointegration, Congress; Milan, Italy, 2001
Clin Oral Implants Res 2001:Aug;12( 4):402. IF: 1.205

61. Garagiola U., Santoro E., Ghiglione V.

Bimaxillary orthognathic surgery with concomitant genioplasty to correct
orofacial deformities.

77th Congress of the European Orthodontic Society; Ghent, Belgium, 2001.

Eur J Orthod 2001:Aug;23(4):450. IF: 0.591

62. Garagiola U., Ghiglione V., Szabò G.

100
 Relationship between postsurgical stability and orofacial muscle activity of
skeletal open-bite deformities.
15th International Conference on Oral and Maxillofacial Surgery; Durban, South
Africa, 2001
Int J Oral Maxillofacial Surg 2001:Jun ;30:87. (suppl) IF: 0.972

63. Garagiola U., Santoro E., Cressoni P., Ghiglione V.

Genioplasty associated with orthognathic surgery in serious orofacial deformity.
8th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Il Futuro
dell’Odontoiatria Ricerca Materiali Tecnologie; Rome, Italy, 2001.

64. Ghiglione V., Garagiola U., Bellintani C.

Aesthetic objectives of orthognathic surgery in the treatment of facial
deformities.
2nd Congresso Nazionale di Medicina Estetica; Milan, Italy, 2000.

65. Garagiola U., Santoro E., Ghiglione V.

Videocephalometric prediction of aesthetic changes in facial tissues in
bimaxillary orthognathic surgery.

XVI Convegno Nazionale SIDO, Florence, Italy, 2000.

66. Garagiola U.
Osseointegration & Orthodontics to achieve optimal aesthetics and function.
XX ICOI World Congress - 30th Anniversary of DGZI., Berlin, Germany,
October 2000.

67. Garagiola U., Ghiglione V., Nishiyama K.

Early diagnosis and multidisciplinary management of the Axenfeld-Rieger
Syndrome.
5th Congress of the European Academy of Paediatric Dentistry; Bergen,
Norway, 2000.

101
68. Garagiola U., Ghiglione V., Maspero C., Fukai M.
Orofacial muscle adaptation after surgical correction of severe anterior open
bite.

76th Congress of the European Orthodontic Society; Crete, Greece, 2000.

Eur J Orthod 2000:Oct;22(4) :444-45. IF: 0.593

69. Garagiola U., Ghiglione V., Maspero C., Nishiyama K.

The orthodontist’s role in the early diagnosis and management of Axenfeld-
Reiger syndrome.

76th Congress of the European Orthodontic Society; Crete, Greece, 2000.

Eur J Orthod 2000:22(5) :579. IF: 0.593

70. Ghiglione V., Garagiola U., Maspero C., Marchetti C.

Multidisciplinary synergism in the early detection and management of Axenfeld-
Rieger Syndrome.
100th Congress of the American Association of Orthodontists; Chicago, USA,
2000.

71. Garagiola U., Ghiglione V., Maspero C.

Orofacial muscle activity patterns after the surgical correction of skeletal open-
bite.
100th Congress of the American Association of Orthodontists; Chicago, USA,
2000.

72. Garagiola U., Ghiglione V., Maspero C.

Use of osseointegrated implants in orthodontic treatment of adult patients.
100th Congress of the American Association of Orthodontists, Chicago, USA,
2000.

73. Garagiola U., Ghiglione V., Cressoni P., Motta B.

The facial profile of the soft tissues after bimaxillary orthognathic surgery.

102
 7th Congresso Nazionale del Collegio dei Docenti di Odontoiatria;
L’Odontoiatria nel Mondo Anno 2000; Rome, Italy, 2000.

74. Ghiglione V., Garagiola U., Bellintani C.

Dento-facial aesthetic motivation in adult orthognathodontics.

7th Congresso Nazionale del Collegio dei Docenti di Odontoiatria;

L’Odontoiatria nel Mondo Anno 2000; Rome, Italy, 2000.

75. Garagiola U., Ghiglione V., Nishiyama K.

Osseointegrated fixtures placement in patients with Ectodermal Dysplasia.
15th Annual Meeting of the Academy of Osseointegration; New Orleans, USA,
2000.
Int J Oral Maxillofacial Implants 2000:15(3):457. IF: 1.316

76. Garagiola U., Bellintani C.

Effects of bimaxillary orthognathic surgery on the profile of the soft tissues of
the face.
1st Congresso Nazionale di Medicina Estetica; Milan, Italy, 1999.

77. Garagiola U., Ghiglione V., Costanza C., Vedani L.

Ectodermal Dysplasia: the role of the orthodontist in its multidisciplinary
treatment.
XV Congresso SIDO; Rome, Italy, 1999.

78. Garagiola U., Ghiglione V., Maspero C., Bellintani C.

Forecast of the effects of bimaxillary orthognathic surgery on the profile of the
soft tissues of the face.
XV Congresso SIDO; Rome, Italy, 1999.

79. Ghiglione V., Garagiola U., Fukai M.

Oral and craniofacial manifestations in patients with Axenfeld-Rieger syndrome.

87th FDI Annual World Dental Congress; Mexico City, Mexico, 1999.

103
 Int Dental J 1999:Oct;49(5):281. IF: 0.713

80. Garagiola U., Ghiglione V.

Relationship between bimaxillary orthognathic surgery and the effects on the
soft tissues in predicting facial changes.
3rd International Danubius Conference on Oral and Maxillofacial Surgery;
Hévìz, Hungary, 1999.

81. Garagiola .U, Ghiglione V., Nishiyama K.

Facial soft tissue profile and aesthetic appearance after bimaxillary surgery.

75th Congress of the European Orthodontic Society; Strasburg, France 1999.

82. Garagiola U., Ghiglione V., Maspero C.

Implant, periodontal, and prosthodontic considerations of NiTi-SE steel
uprighting springs.

75th Congress of the European Orthodontic Society; Strasburg, France, 1999.

Eur J Orthod 1999:Oct;21(5):589. IF: 0.607

83. Garagiola U., Ghiglione V., Nishiyama K.

Soft and hard tissue analysis in treatment planning of patients requiring
orthognathic surgery.
99th Congress of the American Association of Orthodontists, San Diego, USA,
1999.

84. Garagiola, U. Ghiglione V., Hofele C.

Effects of bimaxillary orthognathic surgery on the soft tissues.
14th International Conference on Oral and Maxillofacial Surgery; Washington
DC, USA, 1999.
Int J Oral & Maxillofacial Surg 1999: 28(1):87. (Suppl) IF: 0.948

85. K. Nishiyama, U. Garagiola

An evaluation of treatment system for better implant aesthetics.

104
 ISAOIA; Hong Kong, China, 1999.
Asia-Pacific Dental News 1999.

86. Garagiola U., Maspero C., Bonifacio C., Ghiglione V.

Odontostomatological aspects of Axenfeld-Rieger Syndrome.

6th Congresso Nazionale del Collegio dei Docenti di Odontoiatria; Odontoiatria

Europea Verso il 2000; Roma, Italy, 1999.

87. Garagiola U., Ghiglione V., Nishiyama K.

Use of titanium screw implants for Ectodermal Dysplasia patients.
8th European Association for Osseointegration Congress; Copenhagen,
Denmark, 1999.
Clin Oral Impl Res 1999:10(2):183. IF: 1.816

88. Fukai M., Nishiyama K., Garagiola U.

Sinus lift: Three-dimensional diagnosis by Sim/plant.
X International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 1998.

89. Ghiglione V., Garagiola U., Maspero C.

Orthodontic preparation to implantological-prosthetic rehabilitation.
X International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco 1998.

90. Garagiola U., Ghiglione V., Re E.

Clinical aspects, inheritance patterns, management of x-linked hypohidrotic
Ectodermal Dysplasia.

86th FDI Annual World Dental Congress; Barcelona, Spain, 1998.

Int Dental J 1998: Oct;48(5):424. IF: 0.713

91. Garagiola U., Ghiglione V., Rebagliati M.

Facial soft and hard tissue changes after bimaxillary orthognathic surgery.

105
 86th FDI Annual World Dental Congress; Barcelona, Spain, 1998.
Int Dental J 1998: Oct;48(5):424. IF: 0.713

92. Garagiola U., Ghiglione V., Maspero C.

Skeletal open-bite and the neuromuscular system: surgical vs non-surgical
correction.

74th Congress of the European Orthodontic Society; Mainz, Germany, 1998.

93. Garagiola U., Ghiglione V., Maspero C.

Skeletal open-bite: surgical vs. non surgical treatment.
98th Congress of the American Association of Orthodontists, Dallas, USA, 1998.

94. Garagiola U., Ghiglione V., Maspero C.

Ectodermal Dysplasia: a multidisciplinary approach.
4th Congress of the European Academy of Paediatric Dentistry; Porto Cervo,
Italy, 1998.
Italian J Paediatric dentistry 1998:1:64.

95. Ghiglione V., Maspero C., Garagiola U.

Clinical and therapeutic approach to patients with orthognathodontic surgical
problems combined with cranio-cervical-mandibular dysfunction.

5° Congresso Nazionale del Collegio dei Docenti di Odontoiatria(vol. II);

Odontoiatria Italiana verso il 2000; Rome, Italy, 1998.

96. Garagiola U., Ghiglione V., Marchetti C.

A multidisciplinary approach in patients affected by Ectodermal Dysplasia.

5° Congresso Nazionale del Collegio dei Docenti di Odontoiatria (vol. II);

Odontoiatria Italiana verso il 2000; Rome, Italy, 22nd – 25th April 1998.

97. Garagiola U., Santoro F., Maiorana C., Szabò G., Vìzkelety T.

106
 Special problems before and after the orthognathic surgery on an acrobat patient.
2nd International Danube Symposium of Cranio-Maxillo-Facial Surgery;
Bratislava, Slovenia, 1997.

98. Ghiglione V., Garagiola U., Ciancio P.

Interdisciplinary treatment orthodontics-implantology in the Ectodermal
Dysplasia patients.
IX International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 1997.

99. Garagiola U., Ghiglione V., Ciancio P.

Treatment of the vertical dimension in the deep-bite and open-bite cases by
surgical-orthognathic approach.
IX International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 1997.

100. Ghiglione V., Garagiola U., Maspero C.

Therapeutic approach in the correction of the vertical dimension in skeletal class
III deep-bite and open-bite.

XIV Congresso SIDO;Venice, Italy, 1997.

101. Garagiola U., Ghiglione V., Nishiyama K.

Neuromuscular evaluation of the surgical-orthodontic diagnosis and treatment of
skeletal open-bite.
13th International Conference on Oral and Maxillofacial Surgery; Kyoto, Japan,
1997.
Int J Oral Maxillofacial Surg 1997:1(26):142. IF: 0.749

102. Garagiola U., Ghiglione V.

Aesthetic and functional improvements in the surgical-orthodontic therapy of
skeletal open bite.

73rd Congress of the European Orthodontic Society; Valencia, Spain, 1997.

107
103. Ghiglione V., Garagiola U., Maspero C.
Electromyographic benefits the skeletal Class III Deep-Bite malocclusions after
orthognathic surgery.

97th Congress of the American Association of Orthodontists, Philadelphia, USA,

1997.

104. Garagiola U., Ghiglione V., Ciancio P.

An orthognathodontic-surgical approach in the treatment of the vertical
dimension in skeletal class III Open-Bite.

4th Congresso Nazionale del Collegio dei Docenti di Odontoiatria (vol. II); From
prevention to rehabilitation; Rome, Italy, 1997.

105. Ghiglione V., Garagiola U., Maspero C., Maiorana C.

Aesthetic and functional benefits in orthognatic surgery.
VIII International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 1996.

106. Ghiglione V., Garagiola U., Ciancio P.

An orthodontics-implantology interdisciplinary approach with regards to
functional aesthetics.
VIII International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 1996.

107. Garagiola U., Ghiglione V.

An interdisciplinary treatment to perfect long term results in implantology: Case
report.
Academy of Osseointegration and the European Association for
Osseointegration; Amsterdam, The Netherlands, 1996.

108. Ghiglione V., Garagiola U., Maiorana C.

108
 Importance of electromyography and kinesyography in orthognathodontic-
surgical diagnosis and treatment of the skeletal Class III.

3rd Congresso Nazionale del Collegio dei Docenti di Odontoiatria(vol. II); from
Research at the Clinic; Rome, Italy, 1996.

109. Ghiglione V., Garagiola U., Maiorana C.

An orthodontic-implantology interdisciplinary approach.

3rd Congresso Nazionale del Collegio dei Docenti di Odontoiatria(vol. II); from
Research at the Clinic; Rome, Italy, 1996.

110. Santoro F., Ghiglione V., Garagiola U.

An interdisciplinary approach in implantology: Case Report.

83rd FDI Annual World Dental Congress, Hong Kong, 1995.

Int Dental J 1995:45(5):300. IF: 0.713

111. Santoro F., Maiorana C., Garagiola U.

Use of titanium mesh in the therapy of jawbone atrophies.
12th International Conference on Oral and Maxillofacial Surgery; Budapest,
Hungary, 1995.

112. Santoro F., Maiorana C., Garagiola U.

Jaw resorption on and surgical rehabilitation: a necessity for the future.
2th International Conference on Oral and Maxillofacial Surgery; Budapest,
Hungary, 1995.

109
13.2 - LIST OF ABSTRACTS NON CONNECTED WITH THE TOPIC

1. Garagiola U.
Elastodonzia: indicazioni ed obiettivi in età precoce.
XIX Congresso Nazionale SIDO; Reggia di Caserta, Italia, 2006.

2. Garagiola U., Ghiglione V., Santoro F.

Orofacial deformities and craniomandibular disorders: combined surgical-

orthodontic approach.

6th International Orthodontics Congress; Paris, France, 2005.

3. Ghiglione V., Garagiola U.

Forensic medicine in Clinical Dentistry
XVI International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 2005.

4. Ghiglione V., Garagiola U.

Dentofacial deformities in evolutive patient: Orthopedic-functional treatment.
7° Congresso Nazionale di Medicina Estetica; Milano, Italia, 2005.

5. Garagiola U., Ghiglione V., Santoro F.

Maxillary molar distalization by Pendex appliance.
81st European Orthodontic Society Congress; Amsterdam, The Netherlands,
2005.

6. Garagiola U., Santoro F., Ghiglione V.

Bilateral maxillary molar distalization by Pendex appliance.
105th Congress of the American Association of Orthodontists; San Francisco,
USA, 2005.

7. Ghiglione V., Garagiola U., Santoro F.

110
 Multidisciplinary Gnathologic treatment of Craniomandibular Disorders

XIX Congresso Nazionale SIDO; Rimini, Italia, 2005.

8. Costantinides F., Migliario M., Garagiola U., Gerloni A., Bodin C.

Studio TAC dell’angolo di overjet immediato.
12° Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Roma, Italia,
2005.

9. Ghiglione V., Garagiola U.

Forensic medicine and odontostomatology: clinical cases.
XVI International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 2004.

10. Garagiola U., Ghiglione V.

Mesially tipped molar uprighting in adult: the NiTi-Se steel spring.
XVIII Congresso Nazionale SIDO; Florence, Italy, 2004.

11. Ghiglione V., Garagiola U.

Potential success and risk factors of periodontal tissues in adult othodontics.
XVIII Congresso Nazionale SIDO; Florence, Italy, 2004.

12. Ghiglione V., Garagiola U.

Orthognathodontic aesthetics: psychological motivation and quality of life.
6th Congresso Nazionale di Medicina Estetica; Milan, Italy, 2004.

13. Garagiola U., Ghiglione V., Farronato G.

Appropriate timing of early orthodontic treatment in Class III malocclusion
subjects.
80th European Orthodontic Society Congress; Aarhus, Denmark, 2004.

14. Garagiola U., Ghiglione V., Re E.

Dental and craniofacial anomalies in Silver-Russell Syndrome.

111
 7th Congress of the European Academy of Paediatric Dentistry; Barcelona,
Spain, 2004.
J Paediatric Dentristry 2004:Sep;5:61.

15. Garagiola U., Mortellaro C., Bello L., Dall’Oca S., Palmeri A.
Benefits and limitations in the use of Wilson’s 3D lingual arch.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2004.

16. Garagiola U., Rocchetti V., Matassa A., Dall’Oca S., Migliario M.
The importance of plaque control in the preparation of the surgical parodontal
patient.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2004.

17. Garagiola U., Rocchetti V., Carcieri P., Dall’Oca S., Migliario M.
Protocol for the maintenance of oral hygiene in the hospitalized patient.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2004.

18. Garagiola U., Loguidice M., Dall’Oca S., Migliario M., Rocchetti V.
Protocol for the maintenance of oral hygiene in the patients suffering from
coagulopathy.
11th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2004.

19. Ghiglione V., Garagiola U.

The role of neuromuscular gnathology in the quality of life of dysfunctional
patients.
5th Congresso Nazionale di Medicina Estetica; Milan, Italy, 2003.

20. Garagiola U., Ghiglione V., Farronato G.

112
 Orthodontic aesthetics: motivation and life quality in adult patients.
XVII Convegno Nazionale SIDO; Rimini, Italy, 2003.

21. Garagiola U., Foglio Bonda P.L., Pregarz M., Bodin C.

Temporo-mandibular joint kinetics and chewing cycles in healthy children. A 6
year follow-up.
91th FDI Annual World Dental Congress; Sydney, Australia, 2003.

22. Garagiola U., Bodin C., Pregarz M., Foglio Bonda P.L.
Clinical and radiological study of the temporomandibular osteonecrosis in 50
patients.
91th FDI Annual World Dental Congress; Sydney, Australia, 2003.

23. Garagiola U., Ghiglione V., Spadari F., Maiorana C.

Nd: YAG laser and biocompatibility in orthodontics.
2nd Congress of the European Society for Oral Laser Applications ESOLA – 2nd
Congresso della Società Italiana di Laser in Odontoiatria SILO; Florence, Italy,
2003.
Quintessenz. Verlags 2003:9.

24. Garagiola U., Ghiglione V.

Interdisciplinary parodontology-orthognathodontics synergy: the relationship
between dental movement and parodontal health.
XIV International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 2002.

25. Ghiglione V., Garagiola U.

Neuromuscular evaluation of craniomandibular disorders in orthodontics:
diagnosis and therapy.
XIV International Odontostomatologic Congress; Monte Carlo, Principality of
Monaco, 2002.

113
26. Ghiglione V., Garagiola U.
Aesthetic and neuromuscular evaluation in the three-dimensional diagnostic and
therapeutic protocol of deformities.
4th Congresso Nazionale di Medicina Estetica; Milan, Italy, 2002.

27. Garagiola U., Ghiglione V., Nishiyama K.

Stability and relapse of orofacial deformities after orthognathic surgery.
102nd Congress of the American Association of Orthodontists, Philadelphia,
USA, 2002.

28. Ghiglione V., Maspero C., Garagiola U.

Comparison between two different activators in skeletal class II therapy.
102nd Congress of the American Association of Orthodontists, Philadelphia,
USA, 2002.

29. Maspero C., Biffi S., Garagiola U., Ghiglione V.

Therapeutic effects of Air Rotor Stripping: a clinical case.

9th Congresso Nazionale del Collegio dei Docenti; Rome, Italy, 2002.

30. Maspero C., Santoro E., Garagiola U., Ghiglione V.

Facial mask in combination with a bonded expander: a clinical case.

9th Congresso Nazionale del Collegio dei Docenti; Rome, Italy, 2002.

31. Ghiglione V., Garagiola U., Maspero C., Bellintani C.

Early treatment and prevention of skeletal deformities.

9th Congresso Nazionale del Collegio dei Docenti; Rome, Italy, 2002.

32. Garagiola U., Alicino C., Maspero C., Ghiglione V.

The Pendex in the treatment of Class II without the need for collaboration.

9th Congresso Nazionale del Collegio dei Docenti; Rome, Italy, 2002.

114
33. Bellintani C., Gazzola F., Cressoni P., Farronato G., Garagiola U.
Juvenile idiopathic arthritis, stomatognathic interest: a clinical-diagnostic
protocol.

9th Congresso Nazionale del Collegio dei Docenti; Rome, Italy, 2002.

34. Ghiglione V., Maspero C., Garagiola U., Paini L.

Aesthetic reasons for orthodontic treatment in children and adolescents.
XIII International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 2001.

35. Garagiola U., Gualano M.G., Re E., Ghiglione V.

Parodontal limits, risks and benefits connected with orthodontic movement of
the teeth.

XVI Congresso Nazionale SIDO; Genoa, Italy, 2001.

36. Maspero C., Santoro E., Garagiola U., Ghiglione V.

Diagnosis and treatment in a case of a cyst caused by mandibular eruption.

XVI Congresso Nazionale SIDO; Genoa, Italy, 2001.

37. Ghiglione V., Garagiola U., Cressoni P., Bellintani C.

Aesthetic orthognathodontics: static and dynamic analyses of the soft and hard
tissues of the face.
3rd Congresso Nazionale di Medicina Estetica; Milan, Italy, 2001.

38. Bellintani C., Ghiglione V., Gazzola F., Garagiola U.

Functional orthodontics and correction of facial beauty problems.
3rd Congresso Nazionale di Medicina Estetica; Milan, Italy, 2001.

39. Garagiola U., Ghiglione V., Nishiyama K.

Periodontal benefits, limitations and risks during orthodontic therapy.
89th FDI Annual World Dental Congress, Kuala Lumpur, Malaysia, 2001.

115
 Int Dental J 2001: Oct; 51 (5):368. IF: 0.713

40. Garagiola U., Ghiglione V., Nishiyama K.

Relationship between orthodontic tooth movement and periodontal problems.

77th Congress of the European Orthodontic Society; Ghent, Belgium, 2001.

41. Maspero C., Garagiola U., Ghiglione V.

Diagnosis and therapy of eruption cysts. A case report.

77th Congress of the European Orthodontic Society; Ghent, Belgium, 2001.

42. Ghiglione V., Garagiola U., Nishiyama K.

Nd:YAG laser welding for orthodontic appliances: biocompatibility and
corrosion.

77th Congress of the European Orthodontic Society; Ghent, Belgium, 2001.

43. Ghiglione V., Maspero C., Garagiola U.

Effects of the protraction facemask on vertical dimension – a cephalometric
study.
77th Congress of the European Orthodontic Society; Ghent, Belgium, 2001.
Eur J Orthod 2001:23(5).608. IF: 0.519

44. Garagiola U., Santoro E., Bellucci G., Ghiglione V.

The periodontal tissue in the adult orthognathodontic patient.

8th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2001.

45. Garagiola U., Santoro E., Cressoni P., Ghiglione V.

Uprighting of mesioinclined molars using the NiTi-SE steel spring.

8th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2001.

116
46. Ghiglione V., Garagiola U., Maspero C., Vedani L.
Biocompatibility and electrochemical corrosion of orthodontic materials: the
Nd:YAG laser.

8th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2001.

47. Ghiglione V., Bardare M., Bellintani C., Garagiola U.

Chronic juvenile arthritis: stomatological point of view.

8th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
2001.

48. Bellintani C., Ghiglione V., Garagiola U., Cressoni P.

Orthodontic treatment of dysgnathia.
XXXVII Congresso Nazionale della Società di Reumatologia; Milan, Italy,
2000.

49. Bellintani C., Ghiglione V., Garagiola U., Cressoni P.

Progenism and facial aesthetics: interceptive orthodontics.
2nd Congresso Nazionale di Medicina Estetica; Milan, Italy, 2000.

50. Garagiola U., Ghiglione V., Bellintani C.

Dento-facial aesthetics as a reason for adolescent orthodontic treatment.
2nd Congresso Nazionale di Medicina Estetica; Milan, Italy, 2000.

51. Garagiola U., Ghiglione V., Maspero C.

Periodontal considerations in adult orthodontic treatment.
XII International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 2000.

52. Ghiglione V., Maspero C., Garagiola U.

The periodontal tissue in mixed dentition.

117
 XII International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 2000.

53. Ghiglione V., Bellintani C., Garagiola U.

Prevention and treatment of juvenile rheumatoid arthritis.
5th Congress of the European Academy of Paediatric Dentistry; Bergen,
Norway, 2000.
Eur J Paediatric Dentistry 2000:32.

54. Garagiola U., Maspero C., Ghiglione V.

Orofacial developmental disturbancies and vertical dimension: interceptive
approach.
5th Congress of the European Academy of Paediatric Dentistry; Bergen, Norway,
2000.

55. Garagiola U., Maspero C., Ghiglione V.

The Pendulum appliance in class II therapy.
5th Congress of the European Academy of Paediatric Dentistry; Bergen, Norway,
2000.

56. Garagiola U., Ghiglione V., Ruspa A.

Contributing factors to relapse after surgical correction of skeletal open-bite.

88th FDI Annual World Dental Congress, Paris, France, 2000.

Int Dental J 2000:50(6):334. IF: 0.419

57. Garagiola U., Maspero C., Ghiglione V.

Skeletal Class II therapy – Effects of Bionator and Teuscher appliances.

76th Congress of the European Orthodontic Society, Crete; Greece, 2000.

58. Maspero C., Garagiola U., Ghiglione V.

Protraction facemask reponse with banded and bonded appliances.

118
 76th Congress of the European Orthodontic Society; Crete, Greece, 2000.

59. Maspero C., Ghiglione V., Garagiola U.

Comparison between the protraction facemask response with banded and bonded
appliances.

100th Congress of the American Association of Orthodontists; Chicago, USA,

2000.

60. Bellintani C., Ghiglione V., Garagiola U., Cressoni P.

Chronic infantile rheumatism: stomatognathic interest.

7th Congresso Nazionale del Collegio dei Docenti di Odontoiatria; Rome, Italy,
2000.

61. Ghiglione V., Garagiola U., Bellintani C.

Dento-facial aesthetic harmony in adult orthognathodontics.
1st Congresso Nazionale di Medicina Estetica; Milan, Italy, 1999.

62. Ghiglione V., Maspero C., Garagiola U., Cressoni P.

Distalization of the upper molars in class IIs by the use of the Pendulum.
XV Congresso SIDO; Rome, Italy, 1999.

63. Bellintani C., Ghiglione V., Garagiola U., Maspero C., Farronato G.
A.T.M: Articular damage in juvenile rheumatoid arthritis: prevention and cure.
X Congresso S.I.O.H.; Rome, Italy, 1999.

64. Garagiola U., Ghiglione V., Maspero C.

Aesthetical considerations in adult orthodontic treatment.
XI International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 1999.

65. Garagiola U., Ghiglione V., Nishiyama K.

119
 Implantology and periodontal considerations of using NiTi-SE steel uprighting
springs.

87th FDI Annual World Dental Congress; Mexico City, Mexico, 1999.
Int Dental J 1999:Oct;49(5):282. IF: 0.713

66. Ghiglione V., Garagiola U., Maspero C.

Interceptive orthodontic treatment of serious skeletal discrepancies.
XI International Odontostomatologic Congress; Monte-Carlo, Principality of
Monaco, 1999.

67. Ghiglione V., Maspero C., Garagiola U.

The pendulum appliance in class II therapy.

75th Congress of the European Orthodontic Society; Strasburg, France, 1999.

Eur J Orthod 1999:Aug;21(4):440. IF: 0.607

68. Garagiola U., Ghiglione V., Fukai M.

Craniomandibular disorders: treatment planning using the electromyograph and
kinesyograph.

75th Congress of the European Orthodontic Society, Strasburg, France 1999.

Eur J Orthod 1999:Oct ;21(5):586. IF: 0.607

69. Ghiglione V., Maspero C., Garagiola U.

Ultrasound bone measurement in orthodontic patients with congenitally missing
teeth.

75th Congress of the European Orthodontic Society; Strasburg, France, 1999.

Eur J Orthod 1999:Oct;21(5):588. IF: 0.607

70. Maspero C., Garagiola U., Ghiglione V.

Ultrasound bone measurement in orthodontic patients with osteopenic
pathologies.

75th Congress of the European Orthodontic Society; Strasburg, France, 1999.

120
 Eur J Orthod 1999:Oct;21(5):604. IF: 0.607

71. Ghiglione V., Garagiola U., Maspero C.

NiTi-SE Steel uprighting springs vs other molar uprighting devices.
99th Congress of the American Association of Orthodontists, San Diego, USA,
1999.

72. Ghiglione V., Garagiola U., Bellintani C.

Interceptive orthodontics through the use of Frankel’s function regulator.

6th Congresso Nazionale del Collegio dei Docenti di Odontoiatria; Roma, Italy,
1999.

73. Ghiglione V., Maspero C., Garagiola U.

The role of stabilometry in orthognathodontic diagnosis and therapy.

6th Congresso Nazionale del Collegio dei Docenti di Odontoiatria; Roma, 1999.

74. Maspero C., Ghiglione V., Garagiola U.

The ultrasound densitometer for the diagnostic monitoring of bone tissue in
orthognathodontics.

XV Convegno Nazionale S.I.D.O., Florence, Italy, 1998.

75. Ghiglione V., Garagiola U., Marchetti C.

The contribution of electromyography and kinesiography to the diagnosis of
temporomandibular disorders.
86th FDI Annual World Dental Congress; Barcelona, Spain, 1998.
Int Dental J 1998: Oct;48(5):425. . IF: 0.713

76. Ghiglione V., Maspero C., Garagiola U.

Three-dimensional approach to orthodontic patients with temporomandibular
disorders.

74th Congress of the European Orthodontic Society; Mainz, Germany. 1998.

121
77. Maspero C., Ghiglione V., Garagiola U.
Activation of mandibular growth with the Teuscher appliance. Cephalometric
study of the structural variations in patients with class II malocclusions.

XIV Congresso SIDO, Venice, Italy, 1997.

78. Ghiglione V., Garagiola U., Nishiyama K.

Dentofacial orthopaedic treatment with Teuscher appliance of significant
skeletal discrepancies in children.
FDI Annual World Dental Congress, Seoul, 1997.
Int Dental J 1997: Aug;47:(4):234.

79. Ghiglione V., Maspero C., Garagiola U.

Therapeutic approaches for dental-skeletal and muscular benefits in Class III
patients with skeletal deep bites.
73rd Congress of the European Orthodontic Society; Valencia, Spain, 1997.

80. Garagiola U., Ghiglione V.

An interdisciplinary treatment to perfect long-term results in orthodontics.
97th Congress of the American Association of Orthodontists, Philadelphia, USA,
1997.

81. Ghiglione V., Garagiola U., Maspero C.

Restoration of the skeletal vertical dimension: therapeutic protocol in Deep-Bite
cases.

4th Congresso Nazionale del Collegio dei Docenti di Odontoiatria, Rome, Italy,
1997.

82. Maspero C., Ghiglione V., Garagiola U.

Orthopaedic treatment with Ginevra type monoblock. Cephalometric study of
structural variations in patients with class II malocclusions.

122
 4th Congresso Nazionale del Collegio dei Docenti di Odontoiatria Rome, Italy,
1997.

83. Ghiglione V., Garagiola U., Ciancio P.

A multisciplinary treatment to perfect long term results in orthodontics.
84th FDI Annual World Dental Congress; Orlando, USA, 1996.
Int Dental J 1996:Oct;46(5):459. IF: 0.713

84. Ghiglione V., Garagiola U., Ciancio P.

Neuromuscular Aids to treatment planning of open-bite skeletal Class III
malocclusion.
84th FDI Annual World Dental Congress; Orlando, USA, 1996.
Int Dental J 1996:Oct;46(5):459. . IF: 0.713

85. Ghiglione V., Garagiola U., Ciancio P.

The Bionator in the control of the anterior and posterior vertical dimension in
interceptive orthodontics: presentation of a clinical case.

XIV Congresso Nazionale SIDO; Venice, Italy, 1996.

86. Ghiglione V., Maspero C., Garagiola U.

Control of the anterior-posterior vertical dimension with mixed treatment
(monoblock, Ginevra type). Long term follow-up. Presentation of a clinical case.

XIV Congresso Nazionale SIDO; Venice, Italy, 1996.

87. Ghiglione V., Garagiola U., Maspero C.

Importance of the electromyography for the diagnosis and treatment planning in
interceptive orthodontics.
3rd Congress of the European Academy of Paediatric Dentistry; Bruges,
Belgium, 1996.
Eur J Paediatric Dentistry 1996:71.

88. Ghiglione V., Garagiola U., Ciancio P.

123
 Functional orthopaedics with Teuscher appliance in early treatment of skeletal
Class II malocclusion.
3rd Congress of the European Academy of Paediatric Dentistry; Bruges,
Belgium, 1996.
Eur J Paediatric Dentistry 1996:72.

89. Ghiglione V., Garagiola U., Ciancio P.

The importance of an interdisciplinary approach for the optimization of long
term results in orthodontics.

XIII Convegno Nazionale SIDO; Genoa, Italy, 1995.

90. Ghiglione V., Garagiola U., Restelli L.

Role of interceptive therapy in the long term stability of orthodontic results.

XIII Convegno Nazionale SIDO; Genoa, Italy, 1995.

91. Ghiglione V., Garagiola U., Mori P.

Role of the neuromuscolar system in orthodontic diagnosis and treatment.
2th Congresso Nazionale del Collegio dei Docenti di Odontoiatria; IX Congress
SIOI; Rome, Italy, 1995.

92. Garagiola U., Ghiglione V., Nishiyama K.

Different approaches in the treatment of skeletal deep-bite and open-bite
malocclusions.
85 FDI Annual World Dental Congress, Seoul, 1997.
Int Dental J 1997:Aug;47(4):234. . IF: 0.713

93. Ghiglione V., Garagiola U., Maspero C.

Electromyographic benefits in early treatment of posterior Cross Bite.

XIII Convegno Nazionale SIDO; Florence, Italy, 1994.

94. Ghiglione V., Maspero C., Maiorana C., Garagiola U.

124
Importance of bionator II for the atypic deglutition and muscular activity
2nd Congress of the European Academy of Paediatric Dentistry; Athens, Greece,
1994.
Eur J Paediatric Dentistry 1994:31.

125
14. - ACKNOWLEDGMENTS

I would like to thank Professor Gyorgy Szabò and Professor Franco Santoro my heads,
teachers and mentors both of the profession and of the life, that allowed to constitute the
international twinship between Semmelweis and Milan University and perform PhD
studies.
I would also like to acknowledge Professor Jozsef Barabás that helped me to complete
my PhD Programme and Professor Zsuzsanna Suba for the valuable histological
material.
Furthermore, I wish to thank Professor Carlo Maiorana and Professor Attila Fodor for
their precious guidance and great friendship, that inspirated the University twinship and
afterward my PhD studies.
Thanks to my fabulous staff whose hard work and dedication given to me the
cooperation and time needed to write my PhD Thesis.
My sincerest appreciation to Dani for her invaluable help, support and patience for my
professional career.

126