Results of Computer-Guided Bone Block Harvesting from the Mandible: A Case Series

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1 e111 Results of Computer-Guided Bone Block Hrvesting from the Mndile: A Cse Series 1 Visiting Professor, Deprtment of Periodontology, Dentl Clinic, University of Pdu, Pdu, Itly. Luc De Stvol, DMD, MOM 1 Andre Fincto, DDS 1 Erierto Bressn, DDS, PhD 2 Luc Goto, DDS, MS 3 Autogenous one hrvesting is well-documented surgicl procedure. Autogenous mndiulr one hrvesting crries risk of ntomicl structurl dmge ecuse the surgeon hs no three-dimensionl (3D) control of the osteotomy plnes. The im of this cse series ws to descrie the results of mndiulr one lock hrvesting pplying computer-guided surgery. A smple of 13 prtilly dentte ptients presenting one deficiencies in the horizontl nd/ or verticl plne were selected for utogenous mndiulr one lock grft. The one lock dimension ws plnned through computer-ided design (CAD) process, defining idel one osteotomy plnes to void dmge to ntomicl structures (nerves, teeth roots, etc) nd to generte surgicl guide tht imposed the 3D working direction to the one-cutting instrument. The one lock dimension ws lwys relted to the defect dimension to e compensted. A totl of 13 mndiulr one locks were hrvested to tret 16 lveolr defects (9 verticl nd 7 horizontl). The men plnned mesiodistl dimension of the one lock ws 24.8 ± 7.3 mm, the men height ws 8 ± 1 mm, nd the men thickness ws 4 ± 2 mm. None of the treted ptients experienced neurologic ltertion of their lveolr nerve function. The preliminry dt from this cse series suggested tht computer-guided one hrvesting could e concrete opportunity for clinicins to otin n pproprite volume of utogenous one in sfe mnner. Int J Periodontics Restortive Dent 2017;37:e111 e119. doi: /prd Chirmn, Deprtment of Periodontology, Dentl Clinic, University of Pdu, Pdu, Itly. 3 Visiting Professor, Deprtment of Orl Medicine, Infection nd Immunity, Division of Periodontics Hrvrd School of Dentl Medicine, Boston, Msschusetts, USA. Correspondence to: Dr Luc De Stvol, Pizz Aldo Moro 7, Runo PD, Itly. Fx: Emil: info@dmdent.com 2017 y Quintessence Pulishing Co Inc. Due to its iologic properties, utogenous one is considered the gold stndrd for reconstruction procedures in implnt dentistry. Nevertheless, n utogenous grft involves donor site, nd the surgeon s choice my e introrl. In fct, ptients with extrorl donor sites hve experienced sustntil deteriortion in the physicl component of helth-relted qulity of life compred with ptients treted with introrl donor sites. 1 The choice etween introrl or extrorl is minly dictted y the extent of the defect, nd consequently the quntity of one needed for the reconstruction. Autogenous one lock from the mndile hs een indicted y the 4th ITI Consensus Conference s one of the most predictle wys to mnge horizontl nd verticl one defects. 2,3 Mny uthors hve descried nd proposed instruments nd methods to hrvest mndiulr one lock, such s urs, Piezosurgery, dimond discs, nd sws Limittions of the one lock hrvesting procedure hve een lso reported These limittions re relted to the risk of ntomicl structurl dmge, postopertive ptient moridity, nd insufficient volume t the donor site to tret the defect. 7,12 14 These spects hve surely reduced clinicl ppliction of this pproch. Volume 37, Numer 1, 2017

2 e112 Although ptients don t seem to reject the procedure, recent puliction demonstrted tht 61% of ptients ccepted utologous one ugmenttion if needed. 15 The risk of ntomicl structurl dmge represents the mjor compliction nd the primry limittion of this procedure. Surgeons hve few reference points in the surgicl field to relte to the ntomicl informtion otined through nlysis of the volumetric imge, such s the position of the mndiulr cnl nd teeth roots. Some uthors hve suggested voiding complete cut of the corticl plte in the picl portion of the rmus/externl olique ridge re where the lveolr cnl is locted to overcome the risk of nerve dmge. 7 At present, no instruments or methods descried or used for cutting one cn void risk of ntomicl structurl dmge due ecuse the freehnd tridimensionl working direction is uncontrollle in reltion to these ntomicl structures. Computer-guided implnttion hs een shown to e more precise compred with trditionl freehnd drilling procedures due to the working direction imposed y the surgicl guide In recent study, Arisn et l demonstrted tht the possiility of improperly positioning dentl implnt ws sttisticlly significntly higher with the freehnd method compred with mucosnd one-supported guides. 21 The im of this study ws to descrie the results of the mndiulr computer-guided one hrvesting procedure. Mterils nd methods A totl of 13 prtilly edentulous ptients presenting insufficient one quntity for implnt plcement were selected for utogenous one ugmenttion procedures. All ptients were fully informed out the surgicl procedures nd tretment lterntives. The inclusion criteri were presence of severe one trophy of the lveolr ridge in the horizontl nd/or verticl plne nd dequte one quntity in the donor re of the mndile (externl olique ridge/rmus or chin). Exclusion criteri consisted of one defects following tumor resection, tocco use (more thn 10 cigrettes per dy), severe renl nd/or liver disese, history of rdiotherpy in the hed nd neck region, chemotherpy for tretment of mlignnt tumors t the time of the surgicl procedures, uncontrolled dietes, ctive periodontl disese involving the residul dentition, mucosl disese in the res to e treted, poor orl hygiene, nd noncomplince with utogenous one ugmenttion surgery. Preopertive nlysis included complete medicl history, clinicl nd rdiologic exmintion of the stomtognthic system, nd thorough nlysis of the implnt recipient site nd the one donor site. Cross-sectionl imges (reformtted computed tomogrphic [CT] scns or cone em CT imges) were otined preopertively for ssessment of the crest dimension nd for plnning the one lock hrvesting. The protocol followed during the plnning ws tht descried in the Interntionl Ptent N PCT/ IB2014/ The Digitl Imging nd Communiction in Medicine (DICOM) dtsets were processed with dignostic nd nlysis softwre (3Dignosys 4.0, 3DIEMME) nd the mesiodistl liner defect dimension ws mesured. This mesure ws reported in the re of the mndile most suitle for one lock hrvesting. Using plnning softwre, the ntomicl structures, such s the lveolr cnl, mentl formin, mentl nerve, nd teeth roots present in the re of the donor site, were visulized. Through ech cross-sectionl imge, idel one-cutting plnes were defined, keeping secure mrgin from the ove ntomicl structures (Fig 1). The one lock ws defined in ll dimensions: length, thickness, nd height. The form given to the lock ws rectngulr with crnil, n picl, nd two verticl sides, one mesil nd one distl. The thickness of the cutting instrument ws considered in plnning the lock dimension. Once the cutting plnes were estlished, their projection outside the one ody/surfce defined the internl fces of the surgicl guide (Fig 1). Ech fce guided the cutting tool direction once this the tool ws simply lening ginst the surfce of the surgicl guide. Using computer-ided design (CAD) softwre (PlstyCAD, 3DIEMME) the finl guide design ws shped, including holes for screwing the guide to the one or nchoring it to the occlusl plte of neighoring teeth. All surgicl guides were produced in medicl polymide using computer-ssisted mnufcturing (CAM) process (3Dfst). The Interntionl Journl of Periodontics & Restortive Dentistry

3 e113 Surgicl protocol Antiiotics were prescried to ll ptients (moxicillin [Zimox, Pfizer], 1 g orlly every 12 hours) for 6 dys eginning the dy efore the surgery. Prior to the surgery, ptients were medicted intrvenously with sedtive (Dormicum, Roche). In ll ptients, the surgicl procedure ws performed under infiltrtion of locl nesthesi (Ultrcin DS forte, Snofi-Aventis). The procedure strted in ech ptient with one hrvesting from the mndile. When the externl olique line ws chosen s the donor site, the incision line ws chrcterized y n intrsulculr incision in the molr re, if the teeth were present, or on the top of the lveolr crest in cse of n edentulous ridge. A distl incision rn over the externl olique ridge, while relesing incision ws performed mesilly. A full-thickness flp ws elevted, exposing the externl olique ridge nd the lterl spect of the rmus s well s the lterl spect of the mndiulr ody (Fig 2). The surgicl guide ws screwed to the one with 1.3-mmdimeter screw nd, when plnned, through tooth nchorge (Fig 3). Using piezoelectric instrument (Piezomed, W&H) the osteotomy cuts were mde fcing the flt side of the piezoelectric insert to the internl fce of the surgicl guide (Fig 3). The cutting direction ws unequivoclly defined y the surgicl guide, while the working depth ws defined y the volumetric imge nlysis (Fig 3c). The crnil nd mesil osteotomies were done with the B7 insert, the picl nd distl with the Fig 1 Computer-guided one hrvesting plnning. The cutting plne (green nd white) projection outside the one ody/surfce defined the internl fces of the surgicl guide (yellow). Fig 2 The externl olique ridge fter elevtion of full-thickness flp. Fig 3 () The surgicl guide screwed in in situ. () Using piezoelectric instrument, the osteotomy cuts were mde fcing the flt side of the piezoelectric insert to the internl fce of the surgicl guide. The cutting direction ws unequivoclly defined y the surgicl guide. (c) A clinicl spect of the osteotomies done in ccordnce with the surgicl guide. B2R nd/or B2L (Piezomed, W&H). The lock ws then removed y stright, thin elevtor without the necessity of hmmering (Fig 4). The flp ws sutured with single nd/or c mttress sutures. Where chin one ws hrvested, the incision line ws intrsulculr in the frontl teeth re involving the ses of the ppille nd two distl relesing incisions. Volume 37, Numer 1, 2017

4 e114 Fig 4 Hrvested one lock from the externl olique ridge. Fig 5 () Clinicl view of one lock hrvesting procedure from the chin re. The surgicl guide is screwed to the one nd tooth supported. The flt fce of the surgicl tool ws plced ginst the internl fce of the surgicl guide. () Clinicl spect of the osteotomy cuts done in ccordnce with the surgicl guide. Fig 6 () The one lock ws luxted with thin elevtor. () The hrvested one lock from the chin. Fig 7 () Presurgicl sitution of 6-mm verticl defect in the upper right mxill. () Cross-sectionl imges of the residul one crest. A verticl utogenous one ugmenttion nd sinus lifting ws plnned. Fig 8 () Autogenous one lmine were screwed to uild the vestiulr nd pltl wlls of the lveolr crest. () The spce etween the two one lmine ws filled with utogenous one prticles. The flp ws elevted nd the guide secured to the one s previously descried. All osteotomies were done using the B7 insert (Piezomed, W&H) (Figs 5 nd 6). Once the lock ws removed, the donor site ws filled with collgen sponge. The flp ws stilized with tooth nchorge sutures. In ll cses the one locks were then grfted following Khoury nd Khoury s one ugmenttion pproch 9,23,24 (Figs 7 to 10). The Interntionl Journl of Periodontics & Restortive Dentistry

5 e115 Fig 9 () Clinicl sitution fter 4 months heling. Optiml one reconstruction of the lveolr crest ws chieved. () Three implnts were inserted (XiVE Cell Plus, Dentsply). c Fig 10 () Rdiogrphs of the treted re 4 months fter the implnttion surgery. () Introrl rdiogrph of the implnts fter 12 months of loding. (c) Clinicl view of the finl restortion. Results Demogrphic dt nd defect position nd dimension re reported in Tle 1. A totl of 13 ptients were treted with computer-guided one hrvesting to mnge 16 lveolr deficiencies. The men mesiodistl defect dimension mesured on the preopertive volumetric imges ws 25 ± 6.1 mm (medin: 27 mm). Except for one cse, ll the treted defects were multiple-tooth gps (two to five missing teeth), nd 64% involved gps of three or more missing teeth. In three cses (ptients 3, 11, nd 13), the single hrvested one lock ws grfted in two different qudrnts. In ptient 3, the projected one lock ws 37.5 mm in length nd ws grfted in two verticl one ugmenttions: n 8-mm-height nd 25-mm-length mndiulr defect nd 6.5-mmheight nd 20-mm-length defect in the mxill. In ptient 11, the mm lock ws grfted horizontlly in mxillry nine-teeth defect from the right first premolr to the left second premolr. In five cses, one ws hrvested from the right, nd in six cses, from the left externl olique ridge (see Tle 2). In two cses, the one ws hrvested from the chin. In 3 out of 12 the surgicl guide ws screwed to the one nd tooth supported. The men mesiodistl one lock dimension ws 24.8 ± 7.3 mm. The men height ws 8 ± 1 mm. The men thickness ws 4 ± 2 mm. The men one lock volume from the rmus re ws 0.80 ± 0.51 cm 3. The plnned one locks from the chin re hd men volume of 0.9 cm 3. Following Khoury nd Khoury s one lock mngement pproch, 9,23,24 the one lock ws isected into two thinner corticl lmin nd then grfted in comintion with utogenous prticles one scrped from the sme lmin (Fig 8). When needed, sinus lift procedure ws done in conjunction with the utogenous one grfting procedure. The spce under the sinus memrne ws grfted with deproteinized ovine one prticles (Bio-Oss, Geistlich) mixed with lood. At the reentry fter 4 months of heling, n optiml one reconstruction of the lveolr crest hd Volume 37, Numer 1, 2017

6 e116 Tle 1 Ptient Demogrphic Dt nd Alveolr Defect Chrcteristics Ptient Age (y) Sex (F = femle; M = mle) Defect loction (missing teeth) (FDI) Mesiodistl defect dimension (mm) Type of defect (V = verticl; H = horizontl) 1 50 F 25, V 2 30 F 35, H 3 45 F F V 5 57 F H 6 49 F V 7 29 F 14 9 V 8 55 M V 9 67 M V F 35, V M F V F Men SD V V H H H H Tle 2 Bone Block Dt Donor site loction Guide nchorge Plnned one lock dimension Teeth present t Ptient Right rmus Left rmus Chin Bone Tooth + one Mesiodistl dimension (mm) Men height (mm) Men thickness (mm) Volume (cm 3 ) the donor site (Y = yes; N = no) 1 X X Y 2 X X Y 3 X X N 4 X X N 5 X X Y 6 X X N 7 X X Y 8 X X Y 9 X X Y 10 X X Y 11 X X N 12 X X N 13 X X Y Totl Men SD The Interntionl Journl of Periodontics & Restortive Dentistry

7 e117 een chieved (Fig 9). Three implnts were inserted (XiVE Cell Plus, Dentsply) (Fig 9). Figure 10 shows rdiologic heling of the treted re 4 months fter the implnt surgery (8 months fter the one grfting procedure). After 12 months of loding, n introrl rdiogrph (Fig 10) showed solute stility of the peri-implnt one with no resorption. In cse of mndiulr defect, the followed protocol ws equivlent; implnt surgery ws done 4 months fter the one ugmenttion procedure (Figs 11 13). In nine cses one ws grfted verticlly, nd in seven cses horizontlly. Heling ws uneventful in ll cses nd ptients did not experience ny ltertion in function of the neurologic structures (inferior lveolr nerve nd/or mentl nerve) or of the tooth vitlity in the short or long term. Fig 11 Rdiogrph of 7-mm verticl defect in the posterior left mndile. Fig 12 () Clinicl imge of n utogenous verticl one grft. () Clinicl sitution of the reconstructed lveolr crest 4 months post ugmenttion surgery, when two implnts were inserted. Discussion The im of this cse series ws to descrie the results of procedure for mndiulr one lock hrvesting using computer-guided surgery. Autogenous one hs superior iologic performnce compred with one sustitute, s demonstrted in recent study y De Sntis et l. 25 Nevertheless, utogenous one hrvesting hs limittions. Independent of the method/instrument used, ll the one cuts re done without sure reference points tht could help the surgeon determine the positions of ntomicl structures. So ll osteotomies require gret sfety mrgin, reducing the Fig 13 () Rdiogrph of the treted re 12 months postloding. () Rdiogrph of the sme site fter 3 yers of follow-up. The one level seems to e well mintined. potentil dimension of the hrvestle one lock. In hrvesting one from the rmus re, Clvero nd Lundgren suggested tht the picl one cut should not e done completely through the cortex to void the risk of inferior lveolr nerve dmge. 7 In the superior/sgittl osteotomy, they used just the tip of the sw to void interference with underlying ntomicl structures. 7 Other uthors hve suggested completely voiding the picl osteotomy in the rmus re, insted promoting frcture of the corticl plne. 13 Mny uthors stressed the fct tht osteotomy instruments should not e used in the depth of the one structure due to the clinicl impossiility of controlling the oste- Volume 37, Numer 1, 2017

8 e118 otomy tridimensionl direction. The osteotomy lines should involve just the thickness of the one corticl plte or less, nd the luxtion of the lock should e determined y frcture line generted y lever or y the comintion of one chisel nd hmmer, which my result in intropertive ptient discomfort. Becuse the frcture line runs uncontrolled following minor resistntnce, 7,8 the lock hs to e crefully lifted to ensure tht the inferior lveolr nerve is not trpped within the grft. 7 Computer plnning of the osteotomy lines llows the instruments to e rought deeper into the one, reducing the inner one surfce tht hs to e frctured or voiding frcture completely if the osteotomy lines re plnned to meet. To mintin the front teeth vitlity when hrvesting one in the chin re, Pommer et l suggest sfety zone of 8 mm in the verticl plne from the tooth pexes nd voiding ny osteotomy deeper thn 4 mm. 26 Other studies hve reported tht these sfety mrgins could e reduced to 4 nd 5 mm from the tooth pexes, while the depth limit is determined y the lingul corticl plte. 7,13 Nevertheless, ll the mesures pper to e generlized nd not relted to specific ntomicl chrcteristics of the single ptient to e treted. Bone hrvesting with surgicl guide generted from stereolithogrphic model 27 surely gives the surgeon n opportunity to ring into the surgicl field informtion regrding the superficil position of the osteotomy lines (contour of the hrvestle one lock on the one surfce). No informtion will help the surgeon determine the direction the cutting tool must follow to mke sfe osteotomy. However, computer-guided one hrvesting procedure llows for the osteotomy to e customized to the rel nd specific position of ntomicl structures, minimizing nd/ or voiding risk of dmge. In fct, the superficil position of the osteotomy nd the working directions into the one volume re imposed to the cutting tools y the surgicl guide. Moreover, the ccurcy of the plnned procedures mens the surgeon cn increse the hrvestle one lock dimension, customizing the sfety mrgin for ech ptient sed on the ntomicl structures. In recent study, Verdugo et l 28 clculted the hrvestle one volume from the chin nd from the rmus using CAD softwre. The hrvestle symphysis one volume ws 2.3 ± 0.7 cm 3 (rnge: 0.8 to 4.4 cm 3 ) nd for the rmus, 0.82 ± 0.21 cm 3 (rnge: 0.42 to 1.31 cm 3 ). 28 The re where the one volume ws mesured ws defined nd fixed independently from the rel ntomicl dimension (the rmus re, for exmple, ws defined s the mesurements extended from the midspect of the first mndiulr molr towrd the scending rmus midwy etween the third molr re nd the mndiulr formen; piclly, they extended 5 mm efore reching the inferior lveolr cnl). The uthors did not explin if or how they trnsferred the preopertive nlysis nd mesures otined on the CAD softwre into the surgicl field. In the present protocol, no ntomicl predefined limits were fixed. The hrvestle one volume ws lwys relted to the defect dimension, nd in mny cses this volume ws not in ccordnce with the mximum hrvestle volume from the donor site nd in others the plnned one lock exceeded Verdugo et l s proposed limits. 28 The men one lock volume from the rmus re ws 0.80 ± 0.51 cm 3, with rnge of 0.28 to 2.13 cm 3 (medin 0.70 cm 3 ). The plnned one locks from the chin re hd men volume of 0.9 cm 3. These men vlues re in ccordnce with rnges presented y Verdugo et l. 28 Conclusions The presented method comines the dvntges of computerguided procedure in controlling the osteotomy lines with the ility to mximize nd relte the hrvestle one lock volume to the one volume needed for defect reconstruction. Acknowledgments The uthors reported no conflicts of interest relted to this study. References 1. Reissmnn DR, Dietze B, Vogeler M, Schmelzeisen R, Heydecke G. Impct of donor site for one grft hrvesting for dentl implnts on helth relted nd orl helth-relted qulity of life. Clin Orl Implnts Res 2013;24: The Interntionl Journl of Periodontics & Restortive Dentistry

9 e Chen ST, Begle J, Jensen SS, Chipsco M, Dry I. Consensus sttements nd recommended clinicl procedures regrding surgicl techniques. Int J Orl Mxillofc Implnts 2009;24(suppl): s272 s Jensen SS, Terheyden H. Bone ugmenttion procedures in loclized defects in the lveolr ridge: Clinicl results with different one grfts nd one-sustitute mterils. Int J Orl Mxillofc Implnts 2009;24(suppl):s218 s Misch CM, Misch CE, Resnik RR, Ismil YH. Reconstruction of mxillry lveolr defects with mndiulr symphysis grfts for dentl implnts: A preliminry procedurl report. Int J Orl Mxillofc Implnts 1992;7: Misch CM. Comprison of introrl donor sites for only grfting prior to implnt plcement. Int J Orl Mxillofc Implnts 1997;12: Widmrk G, Andersson B, Ivnoff CJ. Mndiulr one grft in the nterior mxill for single-tooth implnts. Presenttion of surgicl method. Int J Orl Mxillofc Surg 1997;26: Clvero J, Lundgren S. Rmus or chin grfts for mxillry sinus inly nd locl only ugmenttion: Comprison of donor site moridity nd complictions. Clin Implnt Dent Relt Res 2003;5: Khoury F, Hppe A. Zur Dignostik und Methodik von introrlen Knochenentnhmen. Z Zhnrztl Implntol 1999; 15: Khoury F, Khoury C. Mndiulr one lock grfts: Dignosis, instrumenttion, hrvesting techniques nd surgicl procedures. In: Khoury F, Antoun H, Missik P (eds). Bone Augmenttion in Orl Implntology. London: Quintessence, 2007: Vercellotti T. Technologicl chrcteristics nd clinicl indictions of piezoelectric one surgery. Minerv Stomtol 2004; 53: Hppe A. Use of piezoelectric surgicl device to hrvest one grfts from the mndiulr rmus: Report of 40 cses. Int J Periodontics Restortive Dent 2007; 27: von Arx T, Häfliger J, Chppuis V. Neurosensory disturnces following one hrvesting in the symphysis: A prospective clinicl study. Clin Orl Implnts Res 2005;16: Cordro L, Torsello F, Miuccio MT, di Torresnto VM, Eliopoulos D. Mndiulr one hrvesting for lveolr reconstruction nd implnt plcement: Sujective nd ojective cross-sectionl evlution of donor nd recipient site up to 4 yers. Clin Orl Implnts Res 2011;22: Cordro L, Boghi F, Mirisol di Torresnto VM, Torsello F. Reconstruction of the modertely trophic edentulous mxill with mndiulr one grfts. Clin Orl Implnts Res 2013;24: Hof M, Tepper G, Semo B, Arnhrt C, Wtzek G, Pommer B. Ptients perspectives on dentl implnt nd one grft surgery: Questionnire-sed interview survey. Clin Orl Implnts Res 2014;25: Benjmin LS. The evolution of multiplnr dignostic imging: Predictle trnsfer of preopertive nlysis to the surgicl site. J Orl Implntol 2002;28: Gggl A, Schultes G, Kärcher H. Nvigtionl precision of drilling tool preventing dmge to the mndiulr cnl. J Crniomxillofc Surg 2001;29: Hoffmnn J, Westendorff C, Gomez- Romn G, Reinert S. Accurcy of nvigtion- guided socket drilling efore implnt instlltion compred to the conventionl free-hnd method in synthetic edentulous lower jw model. Clin Orl Implnts Res 2005;16: Krmer FJ, Bethge C, Swennen G, Roshl S. Nvigted vs. conventionl implnt insertion for mxillry single tooth replcement. Clin Orl Implnts Res 2005; 16: Westendorff C, Hoffmnn J, Gomez- Romn G, Reinert S. Accurcy nd interindividul outcome of nvigtionguided socket drilling in n experimentl setting. In: Lemke HU (ed). CARS 2005, Proceedings of the 19th Interntionl Congress nd Exhiition, Interntionl Congress Series 1281, ed 1. The Netherlnds: Elsevier, 2005: Arisn V, Krund CZ, Mumcu E, Özdemir T. Implnt positioning errors in freehnd nd computer-ided plcement methods: A single-lind clinicl comprtive study. Int J Mxillofc Implnts 2013;28: De Stvol L, Fincto A (inventors). Method for mking surgicl guide for one hrvesting. PCT/ IB2014/ Apr De Stvol L, Tunkel J. A new pproch to mintennce of regenerted utogenous one volume: Delyed relining with xenogrft nd resorle memrne. Int J Orl Mxillofc Implnts 2013;28: De Stvol L, Tunkel J. Results of verticl one ugmenttion with utogenous one grfts nd the tunnel technique: A clinicl prospective study on ten consecutive treted ptients. Int J Periodontics Restortive Dent 2013;33: De Sntis E, Lng NP, Fvero G, Beolchini M, Morelli F, Botticelli D. Heling t mndiulr lock-grfted sites. An experimentl study in dogs. Clin Orl Implnts Res 2015;26: Pommer B, Tepper G, Ghleitner A, Zechner W, Wtzek G. New sfety mrgins for chin one hrvesting sed on the course of the mndiulr incisive cnl in CT. Clin Orl Implnts Res 2008; 19: Rinldi M, Mottol A, Pgnutti S, Gsrrini A, Borini L. Innesti ossei - modelli STL e guide chirurgiche per i prelievi e gli innesti. In: Rinldi M, Mottol A (eds). Supermento Degli Ostcoli Antomici in Chirurgi Implntre. Implntologi Computer Guidt - Innesti Ossei. Milno: Elsevier Srl, 2009: Verdugo F, Simin K, Rffelli L, D Addon A. Computer-ided design evlution of hrvestle mndiulr one volume: A clinicl nd tomogrphic humn study. Clin Implnt Dent Relt Res 2014;16: Volume 37, Numer 1, 2017