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A. INTRODUCTION
Nowadays, thanks to new applications of science and technology in
medicine, dentistry has made incredible steps in the restoration of missing teeth .
The best fixed prosthodontics treatment is the dental implant. This method helps to
rehabilitate masticatory function, high aesthetics, long-term survival, prevent the
jaw bone resorption, occlusal stability and protect the integrity of remaining teeh;
therefore patients’ life quality is improved. Due to these reasons, implant
technique is the best choice for losing teeth patients. One of the important factors
in this technique is that it needs sufficient bone volume to ensure the success of
masticatory and aesthetic functions. Maxillary bone is spongy and
finely trabecular, thus it usually leads to more bone resorption. Moreover, the
anatomical features of the bone plante at labial aspect in the incisor region is very
thin while the molar region relate to maxillary sinus, so in this anatomical area,
bone defect volume is common and causes many problems for dentists in placing
dental implant. On the other hand, maxillary anterior teeth play an important role in
aesthetic aspect in which clinicians around the world call ”Challenging area” in
dental implant. Because of those clinical situations and demands in reality, we
conduct the research "Research on treatment of partial edentulous maxillae by
dental implant with bone grafting technique” with the following objectives:
1. Describe clinical and X-ray characteristics of partial edentulous patients who
treated by the dental implant with bone grafting technique.
2. Evaluate results of dental implant of patients group above.
3. Comment some factors affecting papillae around dental implant.
IMPORTANCE OF THE DISSERTATION
Implant technique in the maxillae ussually has difficulties because of bone volume
in three-dimension, because the maxilla structure is spongy , contains nasal cavity
and maxillary sinus the bone resorption is fast after losing teeth.To achieve the
required bone volume, most cases of putting implant in front of maxillae have to
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graft onto the bone surface or sinus lift in the posterior area. The factors: bone

of cementum,periodontal ligament and bone bunch make a functional unit. Thus
masticatory force is tranmitted from crowns through tooth roots and attached
tissues to supported hard tissues in the alveolar bone. Losing teeth lead to
significant decrease of edentolous ridge size. It is the reason why implanting
usually combined bone grafting techniques in order to ensure the reasonable bone
volume around the implant.
1.3. Osseointegration : Be the direct connection of the structure and function
betwwen Implant and surrounding bone structure.
1.4. Bone grafting materials: Bone grafting materials have many different
purposes in bone regeneration: Support for membrane, act like a flame to develope
bone, stimulate bone growth, be a mechanical barrier against pressure from the soft
tissue covering above, etc. They include some kinds of bone grafting materials and
biological membranes:
- Bone grafting materials: Autograft, allograft, xenografts , alloplastics.
- Biological membranes: Collagen membrane, PTFE membrane, Titanium
membrane.
1.6.Histological processing in bone grafting procedure: The healing and
regeneration of grafting bone includes three mechanisms: Contact osteogenesis,
osteoconduction, osteoinduction. Bone regenerating procees must have one of
there mechanisms involved in.
1.7. Bone grafting techniques
1.7.1. Grafting bone regeneration with guides (GBR): Over the past 20 years,
there has been a significant progress in the development of the GBR technique in
dental Implant field. GBR has become a basic technique in regenerating the defects
of alveolar bones which makes it possible to perform implant for patients. This
progress is an important part of fast development of dental Implant over time.
1.7.2. Bone grafting and Sinus lift technique: Sufficient bone is the main factor
for the success of dental implant in the maxillae. If the bone height between sinus
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floor to maxillary edentulous ridge crest is less than 10 mm , the bone grafting to

technology, research of variable and convenient connecting form as well as
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equipment and materials used in bone graft , positive results in bone defect applied
GBR technique, simplier and safer sinus augmentation technique, the implant field
has been developed strongly recently, and the successful percentage in the implant
is going to 100% which are the incentives for Clinician in this field.
Chapter 2. Objects and Methodology
2.1. Research objects
Research objects are patients who are 18 years old and over, lose partial
maxillae and are implanted with nondemineralized, freeze-drying allogeneic bone
plots mixed with autologous bone grafts , the surgeries have been conducted at the
Hanoi National Hospital of Odonto-Stomatology from 2009 – 2012.
2.1.1. Selective criteria
- Patients with partial edentulous maxillae whose the height of useful bone
was 5.5to under 10 mm in posterior area and ≥ 10 mm in anterior area, the
minimum width of bone was 4mm, the minimum distance is 6mm, the gap from
bone crest to surface of opposite teeth was ≥ 5mm
- Voluntarily agreed to participate in the study.
2.1.2. Exclusion criteria:
- Patients with contraindications with implant such as: cardiovascular
diseases, diabetes and maxillary sinus diseases.
- Completely edentulous patients
- Patients have undergone radiation therapy in the head-face-neck area.
2.2. Research time and place: From 1/2009 to 3/2009 at Implant Department of
Hanoi National Hospital of Odonto – Stomatology.
2.3. Methodology
2.3.1. Research design: Controlled experimental study
2.3.2. Method to identify model size
- Model size calculation formula:
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only these two systems which had such kind of implant.
- They both designed modernly and suit with current trends for the conservation
purposes of bone and soft tissues around the implant. Planton system was designed
to connect implant and abutment to increase the amount of connective tissues of
bone crest area, then to protect bone crest from adverse factors (bacteria, toxins,
micro motion, etc) in the oral environment in order to be lower the bone resorption
level. Biohorizons was designed 3mm in neck area with small spiral grooves and
had surface treatment by Laser Lok technology to creat stronger soft tissue
attachment which was called soft tissue intergration to protect bone crest around
implant neck area.
2.4.2. Bone graft materials .
Nondemineralized, freeze-drying allergenic bone used in this research was
Miner Oss bone (America) with 50% of trabecular bone to increase
osteoinductional factors and 50% of cortical bone to mantain during 1 year while
helping new bone grow well. In addition, we always took bone broken during
drilling or in scrapers to use to stimulates bone regeneration ability which only had
in autologous bone. Hence bone defects in this research had all factors of contact
osteogenesis, osteoconduction and osteoinduction ( in the autologous bone and
allogenous bone) to ensure better bone grafting results.
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- Absorbable collagen membranes with sizes of 10 x 20 mm, 20 x 30 mm or
30 x 40 mm used in the reasearch were called Mem-Lok (America) for Trademark
which had capability of seft-absorption for 26 – 38 weeks. Mem-Lok membranes
had holes with sufficient sizes to assist large molecules to transfer neccessary
nutrients of healing process and easily adapt to variety kinds of bone defects.
2.5. Research Procedure
2.5.1. Clinical examinations.
2.5.2. X-ray screening
2.5.3. Evaluating the defect forms to choose suitable surgery method.
2.5.4. Other clinical tests.

0
0.0 42 54.5 42 33.3
Total
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100.0 77 100.0 126 100.0
p <0.001
bone defect in the implant neck area was met in 47/126 cases accounting for 37.3%.
bone defect in the implant crown area had 37/126 cases with 29.4% and the 3rd type
of bone defect fell into 33.3%. For back teeth, the most popular bone defect region
belonged to implant neck area (59.2%). The difference between bone defect region
and edentulous position had meaning with p<0.001.
3.1.7. Soft-tissue biotype: For anterior teeth, thin soft tisue type was more
popular with 55.1%, while for posterior teeth, thick soft tissue one owned the
largest percent of 53.2%.
3.1.8. Size of dental implant: Main diameter of 3.3-3.8 mm was used most
(46.8%). All 3.0mm main diameter was for front teeth, while 4.6-4.7-5.8 kinds only
applied for back teeth. Bone group of which width was over 9mm was suitable with
4.6-4.7 main diameter accounting for 84.4%, and it was just 60.6% that bone group
with under 6mm width used main diameter of 3.3 – 3.8mm. The relationship
between main diameter and bone width had meaning with p<0.001.
3.2.Implant results
3.2.1. The initial stability
Diagram 3.1.Initially stable level
In the research our initially stable level was over 35N/cm at 66.67% which was two
times higher than the initial stable level of 20-35 N/cm.
3.2.2. Injury status
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3.2.2.1. Level of pain after surgery: Slightly painful level was at the apex percent
with 39.7%, while painless level was 23% which was seen most in the apex bone
defect region with 19/29 cases or 65.5%. At the crown and neck bone defect region

105
0.33 ± 0.08
105
0.32 ± 0.08
>0.05
p 0.005 0.001
Table 3.20 demonstrated that cases of dehiscence during 7-10 days had higher bone
resorption level compared to cases without dehiscence. The differences had
statistical meaning with p=0.005 for mesial side and p= 0.001 for distal side.
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3.2.3. Bone resorption before prosthesis (in mm):
Table 3.21. Relationship between soft tissues and bone resorption for pre-
prosthesis (mm)
Bone resorption
Soft tissue
Mesial Distal
P
N
X
± SD
n
X
± SD
Thin
60
0.39 ± 0.09
60
0.38 ± 0.11
>0.05
Thick

6.45±0.9
6
37
6.62±0.8
7
42
6.89±1.02
After surgery 44
5.05±1.1
3
37
5.37±1.0
42
6.55±0.95
p 0.000 0.000 0.117
Implants inserted in bone defect positions of neck and crown: Changes of the
keratinized mucosa width before and after surgery had statistical meaning with
p<0.05. Implants inserted in bone defect positions of apex: Changes of the
keratinized mucosa width before and after surgery had statistical meaning with
p>0.05.
3.2.6. Successful percent: 97.6%; eliminated percent: 2.4%.
3.2.9. Results on functional rehabilitation: The ability to rehabilitate
masticatory function of implant prosthesis was always good with high proportions
in different points of evaluation which increased by time (77.2%; 90.6%; 94.6% và
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90%). Poor rehabilitated ability of masticatory function was at lowest percent at
different time of evaluation which decreased by time. Similarly results for aesthetic
rehabilitation ability.
3.2.10. Bone resorption after prosthesis: Bone resorption level rised by time,
but the periods between bone resorption times were shorter. The difference

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Post-prosthesis
time
After 12 months
16 22.9 54 77.1
2.66
(1.11 – 6.42)
0.02
After 6 months
6 8.6 64 91.4
Table 3.28 showed that the amount of full papillae were 2.66 times higher at the
time of 12 months after prosthesis than that at the time of after 6months. The
difference had statistical meaning with p< 0.02.
Table 3.29.Relationship between post-prosthesis time and growing level of the
papillae around the implant (compared between 24 months and 6 months)
Papillae
Post-prosthesis
time
Full Not full RR (95% CI) P
n % n %
After 24 months
29 50.0 29 50.0
7.25
(2.72 – 19.32)
0.001
After 6 months
4 6.9 54 93.1
Table 3.29 showed that the amount of full papillae were 7.25 times higher at the
time of 24 months after prosthesis than that at the time of after 6months. The
difference had statistical meaning with p< 0.001

18.01
(4.14 – 78.40)
<0.001
≤ 2
2 2.0 97 98.0
Total
28 14.4 167 85.6
From the table 3.33 we could see that subjects with over 2mm height of keratinized
mucosa had full papillae ability which was equal to 18.1 times in comparison with
this ability happening in the others of under 2mm of keratinized mucosa. The
difference had statistical meaning at p<0.001.
3.3.4. Bone resorption level
Table 3.34.Relationship between bone resorption level after prosthesis and papillae
size around the implant.
Time
period
Size
6 months
12 months 24 months 36 months
n
X
± SD
n
X
± SD
n
X
± SD
n
X

4
2
0.67±0.09
3 28
0.40±0.3
2
16
0.47±0.1
5
29
0.62±0.8
0
14
0.65±0.08
Table 3.34 indicated that: At the same time, the higher the papillae size, the lower
the bone resorption level. For the same size papillae, their bone resorption level
increased gradually by time at 6,12,24 and 36- month points. The difference had
statistical meaning with p<0.05.
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Chapter 4.DISCUSSION
4.1. Evaluate clinical features and X-ray of reasearch patients
4.1.1. Distribution of subjects by gender and age
4.1.1.1. Gender: In our research, total number of research subjects was 70 patients
in which female: male ratio was equal 64.3: 35.7. This result consisted with studies
of Pham Thanh Ha (2011) with 61.1 female: 38.9 male; of Dam Van Viet (2009)
with 62.85 female: 37.15 male; and of Agnini (2012) with 66.7 female: 33.3 male.
4.1.1.2. Age: Subjects of our research were in many different ages from 19 to 66
years old. Average age of females was: 39.1 ± 14.5 while average age of males was
47.2 ± 14.1 and general average age of all subjects was 42.2 ± 14.8. These figures
were also similar to those from researches of Trinh Hong My (44.9 ± 11.2), of Ta

that thick and thin soft tissue types were similar for both front teeth and back teeth.
However, in the anterior area, the thin soft tissue was more popular at 55.1% with
27/49 cases, meanwhile in the posterior teeth area, majority belonged to thick soft
tissue type (41/77 cases or 53.2%). It was the same for genders as thick soft tissue
was seen more in male with 52.4%. There was no statistically relevant among soft
tissue type, edentulous area and genders of patients at p>0.05
4.1.8. Implant size
4.1.8.1. Relationship between edentulous areaand implant diameter
In our research we excluded the implant with 3.0mm diameter used only for
anterior edentulous area. Most common kind of implant diameter in our research
was 3.3-3.8 mm accounting for 46.8%. Most of this implants were inserted in the
area with small bone width (lower than 6mm). 4.6-4.7-5.8 diameter kinds was used
for the posterior edentulous area. Among them, there were 5/126 cases of 5.8
diameter kind (4%). Hence, in this research, the implants with small and medium
diameter were commonly used. It is also suitable with the trend of clinicians in the
world now thanks to technology to produce these small implants has been gain
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many advances in load-bearing design. Moreover, clinicians realize that
maintaining an amount of full bone tissue around the implant, especially buccal
alveolar bone, is the most important factor to achieve good results in the treatment.
4.1.8.2. Relationship between edentulous are aand the length of implant
Our research demonstrated that implants with 10 – 12 mm in length were
witnessed most at 77% (97 implants) and mainly fell into the back teeth with 75.3%
of 97 implants. This result is also consistent with studies of Guirado (2010) which
conducted 60 implants with sinus augmentation bone graft in 50 patients by 3
implant systems: Osseotite®. Certain®. Prevail® and gave the result: 10 implants
had the length of 10mm, while remaining was 11.5 mm in length. There were
29/126 implants with over 12 length , 86% of which were used for front teeth. This
position usually had convenient height to choose implants with 12-15 mm in length
in order to overcome disadvantages for small diameter implants which were seen in

paresthesia after dental implant which had to treat by injection mixing
Dexamethasone 4mg/ml and 2% Lidocaine (1: 100.000 Epinephrine) with 50:50
ratio. Our research also recorgnized appearing of hematoma blocks (6/126 = 4.8%),
bruising on the cheek and lip area. This ratio in the Schwartz’s study (2005) in 56
patients with autologous bone graft was 12.5% to 16.1% depending on positions
and bone defect classification.
4.2.2.2. Open wounds: The results of our study let us see that the percentage of
open wound complications accounted for 16.7%, in which bone defect region of
implant neck had this complication most with 66.7%. In this area, the bone
defecting position which was covered by grafting bone and biological membranes
was under the edge of the wound, then closing up the wound was more difficult
(this percent in crown of implant: 33.3%).
4.2.3. Bone resorption before prosthesis placement
Our research evaluated the level of bone resorption at the time of screening film
immediatly after fitting prosthesis which indicated that in patients with thin soft
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tissue type, average bone resorption levels were 0.39 ± 0.09 for mesial side and
0.38 ± 0.11 for distal side. On the other hand, for patients with thick soft tissue
type, these levels were corresponding to 0.29 ± 0.06 and 0.30 ± 0.07 for 2 sides.
The different of bone resorption between thin and thick soft tissue types had
statistical meaning at p<0.0001.
4.2.4. The width of keratinized mucosa
The results showed that the width of keratinized mucosa of implants with
bone defect before and after surgery were 6.45±0.96 mm and 5.05±1.13 mm
respectively. In case of bone defect around implant body, the figures were
6.62±0.87 mm and 5.37±1.0 mm. It meant that the width of keratinized
mucosa after bone regenerating surgery with guidance in the bone defect
region of neck and crown areas (window bone defects) were smaller
obviously compared to pre-surgery. For the bone defect region of apex area,
this change was not big which were 6.89±1.02 mm for pre-surgery and

4.3. Factors affecting papillae size around the implant.
4.3.1. Post-prosthesis time
According Cardaropoli’s research (2006), when assessing 11 patients with
maxillae teeth losing at the ages of 18 -36 who were implanted by Branemark
system, the level of more than 50% filling papillae (equal to 2nd degree) increased
form 32% to 86% after 1 year of prosthesis . In our research, full level of papillae
(equal to 3rd degree) also rised with time as follows: 14% after 6 months (28/195
cases), 22,9% after 12 months (16/70 cases). 50% after 24 months (29/58 cases)
and 70% after 36 months (14/20 cases). These figures were suitable with
Cardaropoli’s research (2006). Moreover, our research see that: the number of full
papillae after 12 months was 2.66 times higher than that after 6 months of
prosthesis; and the number of full papillae after 24 months was 7.25 times higher
than that after 6 months. The difference had statistical meaning with p<0.02 and
p<0.001.
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4.3.2. Soft-tissue biotype
In the research of Misisi and colleagues (2012) about the implants on 32
patients with maxillae incisor losing, soft tissues were divided into 2 groups: thin
soft tissue and thick soft tissue. At one-year point after prosthesis, the assessement
showed that the full papillae level of thin soft tissue group was better than one of
thick soft tissue group. As distal as our research was concerned, at 6-month point
after prosthesis (table 3.30), the majority with 79,6% (74/93 cases) for thin soft
tissue is 1st degree papillae size while for thick soft tissue, it was 2nd degree
papillae size at 60,8%( 62/102 cases). In addtion, from table 3.31 we could see that
the ability of full papillae in subjects with thick soft tissue was equal to 15,57 times
compared to that in subjects with thin soft tissue; the difference had statistical
meaning with p<0.001. Hence thick soft tissue gave higher and fuller papillae size
than thin one which led to better aesthetic results.
4.3.3. Keratinized mucosa
4.3.3.1. The width of keratinized mucosa.

- Bones with under-6-mm width were major with 56.3% and mainly in the front area.
For bones with over-9-mm width, there were 25.4% in the back area.
- Bones with equal-or-over-10-mm height accounted for 60.3% and were witnessed
mainly in the front teeth losing area. The remaining had height of 5-to-10 mm, and
was mainly in the back teeth losing area.
- The most popular reason of teeth loss was periodontitis at 46%. Among them, the
anterior teeth loss was significantly due to trauma with 40.8% while for the
posterior teeth, 70.1% of the teeth loss was from periodontitis.
- For jaw bone density in the implant area, the most common type was D3 bone with
54%. D2 bone was more popular in the front edentulous area(69.4%) while in the
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back one it was D3 bone (68.8%). D4 bone was just seen in the posterior area with
9.5%.
- For the back teeth, implant-apex bone defect region had highest percent with 54.2%
while for the front teeth, main bone defect region was the neck of the implant at
59.2%.
- It was equivalent between thick and thin soft tissue.
2. The results of implant treatment with bone grafting techniques
- General successful percentage in our research is 97.6%.
- The recovery abilities of masticatory function at a good level increase from
77.2% to 96.6% proportional over time of the follow-up period.
- The recovery abilities of aesthetic function at a good level increase from
73.2% to 80% proportional over time of the follow-up period.
- The surgical complications: most common complication is incisional
dehiscence with 16.7%, following by bruise or hematomas and sinus
membrane perforation at 4.8% and 1.6%, respectively.
- The implant prosthetic complications: the most common complication is
Broken porcelain crowns with 8,1, going to the 2
nd
and 3

achieve best results in dental implants.
2. Applying and updating new image diagnostic facilities and planning software to get
accurate and safe results to implant.
3. Improving prosthesis Labo’s capacity to satisfy higher and higher demands of
clinical doctors and patients.
4. Finding out and applying prosthesis materials in implants in order to overcome the
risk of broken porcelain crowns and lost contact point etc. as well as convenient
methods when fixing prosthesis during long term of implant care.
5. Selecting the implant system with connecting design, surface treatment and protect
and maintain bone tissue and soft tissue around the implant.
6. Suggesting subjects related to construct the processes and manufacture materials
origined from domestic raw material sources in order to reduce costs for patients.