A Lateral Approach for Sinus Elevation Using

PRGF Technology cid_159 23..31

Eduardo Anitua, PhD, MD, DDS;* Roberto Prado, BS;† Gorka Orive, PhD†

ABSTRACT
Purpose: A lateral approach for sinus elevation using plasma rich in growth factors (PRGF) technology is described. The
long-term survival of dental implants installed following a two-stage procedure after sinus elevation using this procedure
is reported, using implant loss as the outcome variable.
Materials and Methods: A retrospective cohort study design was used. Eighteen patients received 43 implants (BTI implants,
Biotechnology Institute, Vitoria, Spain) with sinus floor elevation. All patients presented a residual bone height of class D
(1–3 mm). Implants were installed using a low-speed drilling procedure (50 rpm) without irrigation. Finally, the histo-
logical and histomorphometric evaluation of eight samples from PRGF grafted sinus involved in the study was carried out
5–6 months posttreatment.
Results: The overall survival rate of dental implants was 100%. The mean follow-up period for all implants was 33 1 7
months ranging from 24 to 44 months. In addition, the histomorphometrical evaluation of the samples evidenced a
25.24 1 4.62% of vital newly formed bone, 50.31 1 15.56% of soft connective tissue, and the remaining 24.46 1 12.79% of
bovine anorganic bone.
Conclusions: Based on these results, this new approach for sinus elevation and implant installation using PRGF technology
can be considered safe, simple, effective, and predictable.
KEY WORDS: lateral approach, PRGF, sinus lift

INTRODUCTION osseointegration and stability of dental implants. In fact,

Implant insertion in the posterior region of the maxilla several studies have reported that a higher rate of
is a challenging procedure. Progressive resorption of implant failures is observed in the upper jaw than other
both horizontal and vertical bone increases the cavity oral regions.3–5
while reducing the thickness of the maxillary sinus The most frequently applied procedure to reestab-
floor.1,2 The absence of upper molars may even increase lish an adequate bone volume and ridge height in the
bone resorption, leading to sinus pneumatization due posterior maxilla is the augmentation of maxillary sinus
to the increased osteoclast activity in the schneiderian floor. The latter involves the modification of the sinus
membrane. These limitations may hamper implant cavity with the aim of generating enough bone volume
installation and negatively affect successful inside a space previously being a portion of the sinus
cavity. The Caldwell-Luc procedure, consisting of a
lateral approach via a trapdoor access to the maxillary
*Scientific director, Biotechnology Institute, Vitoria, Spain;
†
researcher, Biotechnology Institute, Vitoria, Spain sinus was first reported as a sinus lift approach.6–9
Some years later, a less invasive osteotome technique
Reprint requests: Dr. Eduardo Anitua, San Antonio 15, 3° 01005
Vitoria, Spain; e-mail: [email protected] which eliminated the need for a trapdoor access was
described.10–12 In this new approach, elevation of sinus
Source of Funding and Conflict of Interest: The funding for the
present article proceeds from Biotechnology Institute (Vitoria, floor was performed by inward collapse of the residual
Spain). Authors of the manuscript are researchers of the company. crestal floor, using specially designed osteotomes. One
© 2009, Copyright the Authors critical issue to succeed is the correct selection of the
Journal Compilation © 2009, Wiley Periodicals, Inc. appropriate approach for each clinical situation. Some
DOI 10.1111/j.1708-8208.2009.00159.x potential factors that may help the decision-making

e23
e24 Clinical Implant Dentistry and Related Research, Volume 11, Supplement 1, 2009

include the alveolar bone height and width, and the in the study presented a significant alveolar atrophy and a
extent of the desired augmentation among others. residual bone height of class D (1–3 mm).13 A total of 18
According to the consensus held on sinus lifting,13 consecutive patients were selected for the study, 12
when residual bone height is between 1 and 3 mm, a females and 6 males, who received at least one dental
lateral approach involving bone grafting material and a implant in the maxilla for a total number of 43 implants
two-step implant placement is recommended. In the (BTI implants, Biotechnology Institute, Vitoria, Spain)
present article, we describe a lateral approach based on with sinus floor elevation. Smokers were not excluded
the application of the different formulations obtained from the study, but were informed that tobacco use is
from plasma rich in growth factors (PRGF) technology contraindicated in an intra-oral surgery setting as it may
in sinus lift surgery. PRGF is an autologous plasma compromise the efficacy of the sinus lift procedure and
product rich in platelets which enables after activation reduce the long-term survival of implants.
with calcium the local release of multiple growth
factors and bioactive proteins that modulate the pro- Liquid PRGF and Fibrin Elaboration
cesses of wound healing and tissue engineering.14,15 Peripheral blood (20–30 mL) from each patient was
Some distinguishing steps of this new lateral approach taken by venipuncture before surgery and placed
include the use of a mixture of bovine anorganic bone directly into 5-mL tubes (blood collecting tubes®, BTI)
and PRGF-scaffold as sinus graft material, the use of which contain 3.8% (wt/vol) sodium citrate as antico-
liquid PRGF as culture medium to maintain the bone agulant. Liquid PRGF was prepared by centrifugation
window until its reinsertion in its native anatomic loca- (PRGF system®, Vitoria, Spain) at 460 g for 8 minutes at
tion, and the use of autologous fibrin as sealing mem- room temperature. The 0.5 mL plasma fraction located
brane. Additionally, an ultrasonic generator is used to just above the red cell fraction, but not including the
open the bone window which enables an increased buffy coat, was collected and deposited in a glass dish. In
tactile control and avoids soft tissue damage.16 Interest- order to initiate clotting and the formation of a three-
ingly, once the osseous window is separated, it is placed dimensional fibrin matrix for the continuous release of
in a solution of liquid PRGF to maintain its function- growth factors and proteins, PRGF activator® was added
ality until placing it again in its native anatomic loca- to the liquid PRGF preparation (50 mL PRGF activator®
tion. Therefore, the original bone window is conserved per milliliter of preparation). In order to prepare the
and replaced in this new sinus lift approach. Last but autologous fibrin membrane, the milliliter of plasma
not least, in the case of schneiderian membrane perfo- fraction located at the top of the tubes was transferred to
ration, the biocompatible fibrin may be used as autolo- a glass bowl. After adding PRGF activator®, it was incu-
gous sealant biomaterial. bated at 37°C for 40–45 minutes, allowing the formation
Apart from describing this new approach, the long- of a biocompatible fibrin with excellent elastic and
term survival of dental implants installed following a homeostatic properties.
two-stage procedure after sinus elevation using this
procedure is reported, using implant loss as outcome Surgical Protocol
variable. Antibiotics (2 g of amoxicillin clavulanic acid) were
prescribed to each patient, starting 30 minutes before
surgery and during 6 days postsurgically. Midazolam
MATERIALS AND METHODS (7.5 mg, 1 tablet) were also administered 30 minutes
The protocol was approved following the national and preoperatively. Dexamethasone (4 mg) was adminis-
international (International Conference of Harmoniza- tered orally before the surgery and for the next 3 days
tion rules) policies on clinical studies. This study was with a decreasing dose (3, 2, and 1 mg, respectively).
carried out in Vitoria (Spain) and was comprised of Analgesics were used pre- and postoperatively during
patients with a loss of height in the posterior maxilla that 2–3 days. Patients were instructed on how to maintain
required application of a sinus lift technique to allow proper oral hygiene around implants.
rehabilitation with dental implants. The exclusion crite- The operative area was reached by means of a full-
rion was the absence of any local or systemic diseases that thickness flap. As it is illustrated in Figure 1, access to
might contraindicate the treatment. All patients involved the cavity was obtained using a periodontal ultrasonic
 A Lateral Approach for Sinus Elevation Using PRGF Technology e25

Figure 1 Schematic description of the new lateral approach for sinus elevation. (A) The surgical ultrasonic generator is used to
create a vestibular osteotomy. (B) The bone window can be easily separated. (C) The bone window is maintained in liquid PRGF. (D)
The window is easily replaced in its original anatomic location. (E) The bone window is covered with the autologous fibrin. (F)
Reopening 5 months later.

generator (Ultrasonic®, BTI) combined with an inde- membrane rasps to avoid any perforation of the
pendent irrigation system with BTI sterile pyrogen-free schneiderian membrane. Interestingly, in the case of
water. The osteotomy line is made by cutting and dis- schneiderian membrane perforation, the biocompatible
persing the osseous table in a controlled and progressive fibrin may be used as an autologous sealant biomaterial.
way. The ultrasonic tip of the device enables an The autologous fibrin is an alternative biomaterial to the
increased tactile control and avoids soft tissue damage. A collagen membrane. In addition, sinus walls will be
complete osteotomy along the perimeter of the osseous scraped with the help of the ultrasonic device in order to
window is initiated and deepened until tactile sensation promote the vascularization of the area and thus stimu-
of the schneiderian membrane. Once the osseous late the later bone regeneration.
window is separated, it is placed in a solution of liquid The graft material used in the present protocol to fill
PRGF until placing it again in its native anatomic loca- the cavity was a mixture of 1.5–2.5 g. of bovine anor-
tion. Therefore, the original bone window is conserved ganic bone (Bio-Oss®, Geistlich Biomaterials, Wol-
and replaced in this new sinus lift approach. Once the husen, Switzerland) and activated liquid PRGF. The
fenestration is completed, the schneiderian membrane combination of bovine anorganic bone with PRGF
in the sinus floor is carefully separated using the BTI allowed the formation of a clot in which the bovine bone
e26 Clinical Implant Dentistry and Related Research, Volume 11, Supplement 1, 2009

was incorporated. The latter facilitated the manipula- stained with alcian blue and Masson-Goldner trichrome
tion and administration of the bovine bone, increasing to further differentiate and confirm the soft tissue layer,
the biosafety of the approach. In fact, in the case of the grafted bovine hydroxyapatite, and the newly
perforation, the use of PRGF avoids the risks of anor- formed bone. For histomorphometric analysis, histo-
ganic bone particle loss within the sinus cavity. logical samples were examined by conventional optical
One interesting aspect of this approach is that the microscopy using a Leica DMLB microscopy (Leica
original bone window of the sinus is preserved, thus Microsystems, Wetzlar, Germany) and photographed
avoiding the use of artificial membranes. The bone with a digital camera, Canon EOS D30 (Canon Inc.,
window was placed in its original position after turning Tokyo, Japan). The digitalized images were analyzed
it 30°, obtaining an adequate primary stability. using the Image software (version 1.39, National Insti-
The window was covered with autologous fibrin tutes of Health, Bethesda, MD, USA). For determination
and sutured with 5-0 monofilament suture. A detailed of the vital bone content, a 25¥ magnification was used,
description of the sinus elevation protocol is illustrated evaluating the complete section for each case (approxi-
in Figure 1. mately 7.5 mm2). The new bone, bovine hydroxyapatite
Six months after sinus elevation, high-resolution particles and soft tissue areas were measured semi-
scans of the mandibles were acquired with a computed automatically and expressed as percentage of the total
tomography scanner and bone densitometry measured area.
using the BTI scan® program. After evaluating the
situation of the sinus and the schneiderian membrane,
approximately two to three BTI dental implants were Statistical Analyses
installed in each sinus using a two-stage procedure. All Data collection and analysis was performed by two
implant reception sites were prepared using a low-speed independent examiners (other than restorative den-
drilling procedure (50 rpm) without irrigation, as it tists). Descriptive statistics were performed, and abso-
has been described elsewhere.17 Before installation, all lute and relative frequent distributions for qualitative
implants were carefully humidified in liquid PRGF with variables and mean values and standard deviations for
the aim of bioactivating the implant surface.18 The quantitative variables were calculated. Initially, a data-
surgery guides were elaborated and provisional, and base was created using Microsoft Access®. The prin-
final prostheses adapted to each patient were prepared. cipal variable under study was implant loss. By
Four months later, the second surgery was carried out implant loss was considered any implant lost due to
and provisional prosthesis was installed during 8 weeks. biological (failure to achieve osseointegration or loss
Final restoration was carried out with cemented pros- of acquired osseointegration) or biomechanical causes.
thesis using titanium abutments. Between November The rest of variables for data analysis of this report
2003 and July 2007, patients were called in for oral included:
hygiene and clinical and radiographic examinations at
• Gender (female and male).
least twice a year.
• Smoking habits (smoking 31 cigarette per day was
Histological Preparation classified as smoker).
• Implant diameter (ranging from 3.3 to 5.0 mm).
The bone samples used for histological evaluation were
Implant diameter was divided into three categories:
obtained after a healing period of 5–6 months as a
3.3 mm, 3.75–4 mm and 4.5–5 mm.
by-product of implant placement using a trephine
• Implant length (ranging from 7 to 15 mm). Implant
hollow drill, measured 8 mm in length and 2 mm in
length was divided into two categories: 210 mm and
diameter. Processing and staining of the bone samples
>10 mm.
were carried out using a standardized protocol. Briefly,
• Prosthetic factors: divided into cemented bridge,
the samples were fixed in B5-fixative, decalcified with
cemented unitary, hybrid overdenture.
ethylenediaminetetraacetic acid, dehydrated in a graded
series of alcohols, and embedded in paraffin. Then, Data analysis was performed with SPSS 13 for Windows
5-mm-thick serial sections were obtained and stained statistical software package (SPSS Inc., Chicago, IL,
with hematoxylin-eosin. Additional sections were USA).
 A Lateral Approach for Sinus Elevation Using PRGF Technology e27

TABLE 1 Characteristics of the Inserted 43 BTI TABLE 2 Histomorphometric Characterization of the

Dental Implants Percentages of Newly Formed Bone, Connective
Length
Tissue, and Bovine Hydroxyapatite for Each Patient
Time New Bovine Connective
7.0 8.5 10.0 11.5 13.0 15.0 Total
(Months) Bone (%) Hydroxyapatite (%) Tissue (%)
Diameter 3.30 0 1 0 0 0 1 2
6 28.41 43.6 27.99
3.75 2 3 1 0 1 4 11
5 18.52 18.01 63.47
4.00 0 0 0 1 2 7 10
5 21.41 12.5 66.09
4.50 0 0 1 0 0 5 6
5 25.76 13.52 60.72
5.00 0 0 1 2 5 6 14
5 30.56 20.79 48.66
2 4 3 3 8 23 43
5 20.97 14.57 64.46
6 25.33 42.74 31.93
RESULTS 5 30.94 29.92 39.15

Descriptive Analysis
In the present retrospective study, the mean (1standard period for all implants was 33 1 7 months ranging from
deviation) age of the 18 patients was 52 (111) years 24 to 44 months. The follow-up period for 25 out from
(range 29–73) at the beginning of the study. Twelve 43 implants (58.1%) ranged between 12 and 24 months,
patients were female (66.7%) and five patients were clas- whereas the other 18 implants range between 24 and 36
sified as smokers (27.8%). Table 1 shows the length and months. In the present retrospective study, the overall
diameter of the inserted implants. In fact, the length survival rate of dental implants installed after sinus floor
of the inserted 43 implants ranged from 7 to 15 mm, elevation was 100% as no implants were lost during the
whereas the diameter ranged from 3.3 to 5.0 mm. A observational period.
detailed anatomic distribution of the implants is sum- Regarding the histological and histomorphometri-
marized in Figure 2. Regarding the prostheses employed, cal findings, the evaluation of trephine core samples
most of the implants supported cemented bridges evidenced a 25.24 1 4.62% of vital newly formed bone
(51.2%), 15 implants supported hybrid overdentures (while 50.31 1 15.56% represented soft connective tissue
(34.9%), and only 6 implants had unitary cemented and the remaining 24.46 1 12.79% bovine hydroxyapa-
prostheses (14%). tite) in eight sinus grafted with a combination of bovine
As it has been reported, 18 patients received 43 hydroxyapatite and PRGF after a healing period of 5–6
dental implants with sinus floor elevation according months. A detailed characterization of the newly formed
to the protocol described above. The mean follow-up bone, connective tissue, and bovine hydroxyapatite
for each patient is summarized in Table 2. In addition,
Figure 3 shows the histological analysis of a representa-
tive bone biopsy in which new vital bone with abundant
osteocytes can be clearly distinguished. The more
in-depth analysis of the sample reveals several blood
vessels scattered over the connective tissue, the new bone
surrounding the grafted hydroxyapatatite, and multi-
nucleated osteoclasts lying on the mineralized bone
surface.
Finally, Figure 4 illustrates the clinical situation of
a patient involved in the study who received dental
implants following a two-stage procedure after sinus
elevation using the new approach reported in this study.

DISCUSSION
The technique of sinus floor elevation has expanded
Figure 2 Anatomic distribution of the inserted dental implants. prosthetic options by allowing the placement of dental
e28 Clinical Implant Dentistry and Related Research, Volume 11, Supplement 1, 2009

Figure 3 Histological analysis of representative bone biopsy: (A) Haematoxylin-eosin section from tissue made up of 25.76% new
bone (NB), 13.52% bovine hydroxyapatite (HA), and 60.72% connective tissue (CT). (B) Higher magnification of the area marked in
panel A showing new vital bone with abundant osteocytes. Note the presence of osteoclasts (arrows). Several blood vessels can be
observed scattered over the connective tissue (asterisks). (C) Haematoxylin-eosin and (D) alcian blue phomicrographs showing new
bone surrounding the grafted hydroxiapatatite; multinucleated osteoclasts can be observed lying on the mineralized bone surface
(arrows). Collagenized connective tissue in blue is especially evident in the alcian blue staining (stainings: A, B C,
Haematoxylin-eosin; D, alcian blue) (Scale bars: A, 700 mm; B, C, D, 200 mm).

implants in maxillary segments with atrophic ridges and viability of the bone window, biosafety, and even bone
pneumatized sinuses. In the present study, we describe regeneration.
and evaluate the biosafety and efficacy of a lateral An ultrasonic generator is used to create the osteo-
approach for sinus lift specifically recommended for tomy. The ultrasounds generated at the active tip of the
severely resorbed maxillae. In these situations, the selec- device facilitate the opening of the bone window.
tion of a lateral approach for the sinus elevations and a The osteotomy line can be easily made by cutting the
two-stage technique for implant installation is highly osseous table in a progressive, precise, and controlled
recommended. Additionally, bone graft insertion is way.16 Another interesting property of the ultrasonic
frequently used with the aim of increasing the bony device is that it provides greater tactile control and mini-
support for oral implants.19,20 In fact, it is important to mizes the damage on surrounding soft tissues, reducing
remember that the clinician always aims to preserve an clearly the risks of perforating the schneiderian mem-
adequate and viable bony mass to meet the future brane. In addition, the visualization of the surgical area
implant-prosthetic requirements. is improved because of the cleaning effect of the irriga-
The new lateral approach described in this study has tion liquid under the action of the ultrasounds. In fact,
some distinguishing and specific characteristics which the latter transforms the liquid jet into a low-pressure
may offer potential advantages compared with con- aerosol that facilitates the cleaning of the area, reducing
ventional sinus elevation surgery. These include, for the risks of subcutaneous emphysema. The thin cutting
example, the use of a surgical ultrasonic generator to provided by the ultrasonic device facilitated the removal
create a vestibular osteotomy, a low-speed drilling pro- and the posterior reinsertion of the bone window after a
cedure for implant installation, and the application slight adjustment.
of PRGF technology in several steps of the lateral The most important innovation of this sinus lift
approach.15,21 As a consequence, there is a significant approach relies on the application of PRGF technology
improvement in terms of manipulation of the graft, into several key steps of the protocol. The preparation
 A Lateral Approach for Sinus Elevation Using PRGF Technology e29

Figure 4 Forty-eight-year-old woman with partial edentoulism. (A) The treatment plan for the upper maxilla required 2 sinus
elevations. (B) Pretreatment radiograph. (C) The bone-window is reinserted in its native location. (D) Radiograph of the patient 5
months posttreatment. (E) Reopening 5 months posttreatment. (F) Radiograph 2 years posttreatment. (G) Image of the patient
before the treatment. (H) Image 1 year after the treatment.

rich in growth factors (PRGF) is an optimized platelet- activator, respectively. The former protects the platelets
rich product.14,15,21 First, it is a 100% autologous product from fragmentation avoiding the loss of growth factor
that it is easily and rapidly obtained from patient’s content, while the latter enables a safer and a more sus-
blood, and because the donor and receptor is the same, tained and physiological release of the stored growth
the immunological concerns are circumvented. PRGF is factors.22 This is particularly interesting as the potential
obtained from a simple spin method and using small risks associated with the bovine thrombin are avoided.
and variable blood volume depending on the type of From a safety point of view, PRGF does not contain
surgery. In the PRGF preparation, sodium citrate and neutrophils which express matrix-degrading enzymes
calcium chloride are used as anticoagulant and clot that could destroy surrounding injured or healthy cells.
e30 Clinical Implant Dentistry and Related Research, Volume 11, Supplement 1, 2009

Last but not least, by controlling the elaboration protocol elevation, all implants were installed following a low-
and coagulation degree of the samples, it is possible to speed drilling procedure without irrigation and humidi-
obtain almost four different formulations with ther- fied with PRGF before insertion.17,30
apeutic potential,15 including the PRGF supernatant, the The findings from this present retrospective study
liquid PRGF that can be used to bioactivate dental indicate that the new lateral protocol described for sinus
implants in order to improve their osseointegration,18,23 elevation and posterior implant installation provides a
the scaffold-like PRGF with potential to promote bone safe, successful, and predictable treatment procedure. In
and soft tissue regeneration, and the biocompatible and fact, 18 patients received 43 dental implants after sinus
elastic fibrin which can be used as an autologous sealant elevation and the survival of the latter was followed-up
biomaterial in the case of schneiderian membrane perfo- during 33 1 7 months. Results show that survival rate of
ration. Moreover, the same fibrin membrane is used to the implants was 100%. No remarkable side effects such
seal the implant defects with the aim of preventing the as pain, infection, or major inflammation were observed
invasion of soft tissues which may reduce the amount and during the study time period. An excellent epithelization
quality of newly formed bone. of soft tissues was detected.
The rationale for using PRGF is that provides a The histological analysis of a representative bone
natural source of proteins such as fibrinogen, fibronec- biopsy revealed new vital bone with abundant osteo-
tin and vitronectin, and growth factors including cytes and several blood vessels scattered over the con-
platelet-derived growth factor, transforming growth nective tissue. The histomorphometric analysis of the
factor-b, vascular endothelial growth factor, insulin-like samples showed an average of newly formed bone
growth factor, hepatocyte growth factor, angiopoietins, higher than 25%. Future studies are under preparation
platelet factor-4, and thrombospondin among others to to evaluate the potential of PRGF-derived growth factors
the local milieu, which may drive tissue regeneration in promoting and accelerating bone regeneration.
mechanisms.23 In addition, the combination of these In summary, this study describes a new lateral
formulations with biomaterials may increase the versa- approach for sinus elevation and two-stage implant
tility of the technology. Assuming this knowledge, a placement using a surgical ultrasonic generator, a low-
mixture of bovine anorganic bone and PRGF was speed drilling procedure for implant installation, and
employed as graft material. The use of this biological especially PRGF technology. The survival rate of
graft in sinus lift not only provides a pool of growth implants installed following this procedure was 100%. It
factors to the local environment but also facilitates is also important to remark that the present technology is
the handling, manipulation, and administration of the cheap for the patient and easy for the clinicians Prelimi-
anorganic bone particles, and increases the overall nary results of this retrospective study suggest that this
volume of the graft. This is especially interesting and new protocol can be considered safe and predictable.
definitive in the case of membrane perforation. Waiting for future prospective studies, the results herein
Although much work lies ahead in order to properly reported may be helpful for clinicians to improve their
evaluate and characterize the role of PRGF in this bio- decision making and thus enhance implant success.
logical graft, some studies have reported beneficial out-
comes when a platelet rich product was combined with ACKNOWLEDGMENTS
different bone substitutes (autogenous, allogenic, or
The work of this group is partially funded by the Basque
alloplastic) for sinus floor elevation.24–28
and Spanish governments. The funding for the present
The liquid PRGF can be used as culture medium
article proceeds from Biotechnology Institute (Vitoria,
to maintain the viability and functional properties of
Spain). Authors of the manuscript are researchers for the
autologous bone.29 Assuming this, another key applica-
company.
tion of PRGF in this protocol is to provide a biological
active medium that will conserve the functional proper-
ties of the osseous window. Therefore, in this approach, CONFLICTS OF INTEREST STATEMENT
the original bone window of the sinus is preserved and Funding for the present article proceeds from the
reinstalled in its original position, thus avoiding the use Biotechnology Institute, (BPI, Vitoria, Spain). The
of artificial membranes. Last but not least, after sinus authors of the article are researchers of the company.
 A Lateral Approach for Sinus Elevation Using PRGF Technology e31

[Correction added after online publication 23 October 17. Anitua E, Carda C, Andia I. A novel drilling procedure and
2009: Conflicts of Interest Statement added.] subsequent bone autograft preparation: a technical note. Int
J Oral Maxillofac Implants 2007; 22:138–145.
18. Anitua E. Enhancement of osseointegration by generating a
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