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ORIGINAL ARTICLE

The efficacy of synthetic allograft and bioresorbable

xenograft in immediate implant procedures:
A comparative clinical study
Diana Daniel, Vidya Shetty, Jerin Jose, A Harish Kumar, B S Santosh, S P Saikrrupa

ABSTRACT

Aim: Immediate placement of an implant into the fresh extraction socket often leaves a space between
the implant periphery and the surrounding bone, and the space between the implant and the bone is
required to be filled with a biocompatible material such as a graft. This study aimed to compare the
efficacy of synthetic bioactive glass allograft and dried freeze bovine bone grafts in the immediate
implant site.
Materials and Methods: The study comprised a total of thirty individuals in the age group
between 16 and 60 years with at least one tooth indicated for extraction. The thirty participants were
further divided into two groups. Group A comprised 15 participants who underwent extraction and
buccal plate preservation (BPP), followed by immediate implant placement using synthetic allograft
material (PerioGlas). Group B comprised 15 participants who underwent extraction and BPP, followed
by immediate implant placement using xenograft as the graft material (Bio‑Oss). The participants
were evaluated both clinically and radiographically for 3 months, 6 months, and 1 year. The level of
significance was set at P < 0.05.
Results: PerioGlas and Bio‑Oss in immediate implant site showed excellent osseointegration around
the immediate implant site. However, the difference between the groups was not statistically significant.
Conclusion: Both synthetic allograft and bioresorbable xenograft are promising and equally potential
in bone formation around the immediate implant site.

KEY WORDS: Allograft, immediate implants, osseointegration, xenograft

INTRODUCTION and quality of life of an individual.  The emergence

of osseointegration and advances in biomaterials and
The long state of edentulism can compromise not only techniques has contributed to increased application
the function but also it might affect the self‑confidence of dental implants in the restoration of partial and
completely edentulous patients. Immediate implant
Department of Oral and Maxillofacial Surgery, Oxford Dental placement has become a favored treatment protocol
College, Bengaluru, Karnataka, India by many clinicians worldwide. The immediate implant
Address for correspondence: Dr. Jerin Jose, procedure outweighs the delayed implant placement
Department of Oral and Maxillofacial Surgery, Oxford Dental College, Bengaluru,
Karnataka, India.
first because it preserves alveolar bone height and
E‑mail: jessicajose19@gmail.com width. Second, it avoids a second surgery with an
Received: 09‑Jun‑2020,  Accepted: 12‑Oct‑2020,  Published: 18-Dec-2020
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which
Access this article online allows others to remix, tweak, and build upon the work non‑commercially, as
long as appropriate credit is given and the new creations are licensed under
Quick Response Code: the identical terms.
Website:
www.jdionline.org For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Daniel D, Shetty V, Jose J, Kumar AH,

DOI: Santosh BS, Saikrrupa SP. The efficacy of synthetic allograft and
10.4103/jdi.jdi_12_20 bioresorbable xenograft in immediate implant procedures: A comparative
clinical study. J Dent Implant 2020;10:93-8.

© 2020 Journal of Dental Implants | Published by Wolters Kluwer - Medknow 93

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Daniel, et al.: Bone grafts in immediate implant site
added advantage of less operator time. Third, it causes
less trauma to the tissues and discomfort to the patient.
Overall, it improves the function and esthetics of
the individual.[1,2] To achieve an optimum treatment
outcome with dental implants, adequate bone should
be available to support and stabilize them. Although
advanced diagnostic facilities are available, it is a
challenge to placing an implant with the same extracted
tooth dimensions. For enhanced osseointegration,
and to prevent buccal plate resorption in an extracted
socket, the space between the implant and the socket
needs to be filled with a biocompatible material such as
a graft.[2,3] Buccal plate preservation (BPP) counteracts
the changes in the esthetic zone of the soft tissue and
maintains the contour while permitting natural socket
healing. Besides, in the BPP technique, grafts are placed
outside rather than inside the socket.[4,5] The autogenous
bone graft is considered the gold standard because it
has got an excellent osteogenic, osteoinductive, and
osteoconductive properties without the risk of graft
rejection or adverse reactions. However, because of its
donor‑site morbidity and unpredictable resorption, a
range of biomaterials, primarily bone xenografts and
allografts, are used in the immediate implant site. [5]
Synthetic allografts and xenografts are osteoconductive
materials with low resorbability and provide primary
stability with limited socket resorption. Bio‑Oss is
a biocompatible material that is more stable with a
slow resorption rate and, in turn, helps in new bone
formation.[6,7] PerioGlas is an alloplastic material with
osteoconductive properties. It acts as a scaffold for bone
formation. It has no possible risk of cross‑infection or
disease transmission; moreover, it is easily available.[6,7]
However, this study attempted to compare the efficacy
of synthetic allograft and bioresorbable xenograft in the
immediate implant site for enhanced osseointegration.
MATERIALS AND METHODS
A comparative clinical study was conducted on
individuals who reported to the Outpatient Department,
Oxford Dental College, Bommanahalli, Bengaluru. A total
of 30 individuals, including both men and women, aged
between 16 and 60 years, were enrolled in the study. The
thirty participants were further divided into two groups.
Group A comprised 15 participants who underwent
extraction and BPP, followed by immediate implant
placement using synthetic allograft material (PerioGlas).
Group B comprised 15 participants who underwent
extraction and BPP, followed by immediate implant
placement using xenograft as the graft material (Bio‑Oss).
The inclusion criteria were as follows: individuals with
at least one tooth indicated for extraction with sufficient
bone quality and quantity around the implant site and
individuals with good systemic health and oral hygiene.
The exclusion criteria were as follows: patients with
94 Journal of Dental Implants | Volume 10 | Issue 2 | July-December 2020
any local infection around the implant site, pregnant or
lactating mothers, patients with any systemic disease,
individuals with a history of smoking habits, those who
had or were undergoing irradiation therapy, patients
on anticoagulant therapy, and patients with an existing
condition or disease that would interfere with good
mucosal and bone healing. Ethical clearance was obtained
from the Institutional Ethical Committee on November
10, 2016, Ref No: 192/2016‑17. Informed consent was also
obtained from each individual for their participation in
the study. Before placing implants, a detailed case history,
intraoral, extraoral, and radiographic examination was
done. This was followed by implant placement using
standardized clinical and laboratory protocols.
Surgical procedures
Surgery was performed under local anesthesia (2% lignocaine
with 1:200,000 concentration of adrenaline). Surgical
procedures were carried under proper aseptic conditions.
The teeth indicated for extractions were removed
atraumatically. The sockets were then further evaluated
on a computed tomography scan for any dimensional
changes, and the final decision regarding the dimensions
of the implant was taken. A crevicular incision was around
the implant site. Full‑thickness subperiosteal labial and
palatal flaps were reflected to expose the crest to provide
visualization of the buccal and lingual bone plates.
A surgical pouch was created on the buccal/labial side
using a periosteal elevator.
A pilot drill, usually 2 mm in diameter, was drilled at the
implant site to establish the depth and axis of the implant
recipient site. The implant was placed with its axis parallel
to the occlusal forces. Furthermore, parallel pins were used
to check the parallelism of the drill holes to the adjacent
teeth. The drill was used in a reduction gear handpiece
along with a physio‑dispenser, enabling internal and
external irrigation to prevent excessive heat generation.
Sequential drilling at 800–1000 rpm was carried out until
the desired dimensions depended on the required size
of the implant. Furthermore, the implant (genesis) of
size (4.0 mm × 11 mm and 3.5 mm × 11 mm) was placed,
respectively, into the prepared site using a torque wrench.
The discrepancies between the implant and walls of the
socket were evaluated in all the thirty participants, and a
bone graft was placed in the created surgical pouch of 15
sockets with synthetic allograft material (PerioGlas) and
15 sockets with xenograft (Bio‑Oss) [Figures 1 and 2]. The
membrane was placed over the graft, and 3‑0 vicryl sutures
were used to close the surgical wound. Oral hygiene
instructions were given to patients and were followed
up periodically both clinically and radiographically for
1 year.
Soft‑tissue evaluation criteria
Evaluation of the soft tissue was done at four sites (mesial,
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Daniel, et al.: Bone grafts in immediate implant site
a
c c
d f
Figure 1: (a) Immediate implant site, (b) PerioGlas as the graft
material, (c) implant placement along with PerioGlas as the
graft material, (d) 6-month postoperative radiograph, (e) clinical
picture after 1-year follow-up
buccal, distal, and lingual) using a modified plaque
index, gingival index, and by measuring the probing
depth. Probing depth was measured using a calibrated
probe at both the full‑mouth (FM) site and the Immediate
implantation site (IMP).
Radiographic evaluation criteria
Intraoral periapical (IOPA) radiographs were taken
using the long‑cone paralleling technique. The
radiograph was assessed at 3 months, 6 months,
and 1 year. The radiographs were then analyzed
using  CorelDRAW software Software from Corel
Corporation, Montreal,Quebec,Canada. The IOPA
radiographs were transferred to the computer, enlarged
to the actual implant size, and the amount of bone
resorption was measured from the crestal bone level to
the implant crest module at the mesial and distal sites.
Success criteria
The success of the implant was assessed based on
the following criteria: first, the absence of any sign of
peri‑implant inflammation or infection both clinically
and radiographically at the implant site, and second, the
absence of clinical mobility.
Statistical power analysis
The Statistical Package for the Social Sciences for
Windows version 22.0 released 2013. IBM Corp.,
Armonk, NY, USA, performed the statistical analyses.
The sample size was calculated using power analysis
at 80% power of the study. The total sample size of the
Journal of Dental Implants | Volume 10 | Issue 2 | July-December 2020 95
a
d e
Figure 2: (a) Immediate implant site, (b) Bio-Oss as the graft
material, (c) implant placement along with Bio-Oss as the graft
material, (d) 6-month postoperative radiograph, (e) clinical
picture after 1-year follow-up
study was 30 individuals. Each group consisted of 15
individuals. The Mann–Whitney U‑test was used to
compare the mean values of various study parameters
between the two groups at different time intervals.
Friedman’s test, followed by the Wilcoxon signed‑rank
test as post hoc analysis, was used to compare the mean
values of various study parameters between different
time intervals in both Group A and Group B. The level
of significance was set at P < 0.05.
RESULTS
The present study aimed to evaluate the efficacy of
synthetic allograft and bioresorbable xenograft in
the immediate implant site. For this purpose, we
placed 15 implants of size 4.0 mm × 11 mm with
allograft material (PerioGlas) and 15 implants of size
3.5 mm × 11 mm with bioresorbable xenograft (Bio‑Oss),
respectively, in the immediate implant site. All the
patients included in the study were between the ages of
16 and 60 years. Of the 30 patients, 18 patients were female
and 12 were male. The treatment outcome was evaluated
both clinically and radiographically for a period of 1 year.
Table 1 shows the comparison between mean plaque
index values between Groups A and B in different periods
at different sites. The treatment procedure was effective
by placing both allograft and xenograft in the immediate
implant site. At the end of 1 year, the plaque index values
for Groups A and B were 0.68 and 0.7, respectively.
However, comparing the plaque index values at
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Daniel, et al.: Bone grafts in immediate implant site

3 months, 6 months, and 1 year between Groups A and However, there was no statistically significant between
B showed no statistically significant difference [Table 1]. the two groups [Table 3].

Table 2 shows the comparison between mean gingival index
values between Groups A and B for different sites (FM and
IMP) 3 months, 6 months, and 1 year. In Group A, the
FM gingival index was as follows: 0.86 ± 021 at 3 months,
0.82 ± 0.41 at 6 months, and 0.86 ± 0.31 at 1 year. Similarly,
in Group B, the FM was 79 ± 0.24 at 3 months, 0.84 ± 0.31
at 6 months, and 0.82 ± 0.12 at 1 year. However, in the IMP
site, the gingival index of Group A was as follows: 0.93 ± 0.25
at 3 months, 0.83 ± 0.26 at 6 months, and 0.94 ± 0.21 at 1 year,
and in Group B, the IMP gingival index was 0.84 ± 0.2 at 3
months, 0.78 ± 0.27 at 6 months, and 0.80 ± 0.26 at the end
of 1 year. Clinically excellent healing was observed after
placement of the implant with both allograft and xenograft.
Moreover, there were no signs of inflammation.   However,
a comparison of the mean gingival index in both Groups
A and B showed no statistically significant difference. This
could be due to the good oral hygiene routine maintained
by the participants [Table 2].
Table 3 demonstrates the values of probing depth in
mesial, distal, buccal, and lingual sites at 3 months,
6 months, and 1 year. The results showed that the
probing depth was further decreased over a period of
1 year, suggesting that the implant has good stability.
Table 4 demonstrates a considerable amount of bone
resorption around the implant on the mesial and distal
sites for both the groups at 3 months, 6 months, and
1  year. However, there was no statistically significant
difference between the groups. These results suggest a
good implant to bone osseointegration [Table 4].
DISCUSSION
In the past two decades, implants have become one of the
most exciting and rapidly developing treatment options
in dental practice because of the high predictability
of treatment outcomes compared to conventional
prosthodontics. The emergence of the concept of
osseointegration has contributed to an increase in the
application of dental implants in the restoration of
partially and completely edentulous patients. Immediate
implant placement after extraction has become a favored
treatment protocol as the natural socket has abundant
periodontal cells and matrix, which promotes rapid
healing and further decreases the risk of bone necrosis.
Moreover, it eliminates the waiting period for socket
ossification, fewer surgical sessions required, shortened

Table 1: Demonstrate the comparison between mean plaque index values between groups A & B for
a period of 3M, 6M, and 1 year at different sites
Time interval Group Mean full mouth plaque index P Mean implant site plaque index P
3 months Group A 0.64±o. 26 o.88 0.74±0.19 0.71
Group B 0.65±o. 22 0.72±0.24
6 months Group A 0.8±o. 26 o.88 0.76±0.17 0.80
Group B 0.82±0.22 0.78±0.12
1 year Group A 0.7±0.25 0.67 0.7±0.22 0.38
Group B 0.68±0.25 0.7±0.18

Table 2: Demonstrate the comparison between mean gingival index values between groups A & B for
different sites (FM & IMP) from baseline to 6 months
Time interval Group Full mouth gingival index P Implant site Gingival index P
3 months Group A 0.79±0.24 0.41 0.84±0.2 0.38
Group B 0.86±021 0.93±0.25
6 months Group A 0.84±0.31 0.32 0.78±0.27 0.28
Group B 082±0.41 0.83±0.26
1 year Group A 082±0.12 0.21 0.80±0.26 0.38

Table 3: Demonstrate the mean values of probing depth which was evaluated at 6M, and 1 year
Group Time Mesial P Distal P Buccal P lingual
Group A 6M 2.30±0.34 0.44 2.23±0.28 0.84 2.21±0.29 0.75 2.26±0.24
Group B 2.40±0.36 2.21±0.29 2.24±0.28 2.31±0.34
Group A 1 Year 2.10±0.36 0.16 2.23±0.28 0.80 2.21±0.29 0.84 2.04±28
Group B 2.27±0.27 2.21±0.29 2.19±0.28 2.07±36

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Daniel, et al.: Bone grafts in immediate implant site
Table 4: Demonstrate the considerable amount
of bone resorption around the implant both on
mesial and distal sites for both the groups at
3M, 6M, 1 year
Group Time Mesial P Distal
Group A 3M 4.93±0.4 0.58 5.02±0.36
Group B 5.01±0.35 4.95±0.44
Group A 6M 3.36±0.46 0.93 3.65±0.5
Group B 3.61±0.46 3.68±0.42
Group A 1 year 3.27±0.41 0.62 3.13±0.37
Group B 3.13±0.37 3.27±0.39
edentulous period, reduced overall cost, preservation of
alveolar bone height and width, and decreased operatory
time with less trauma to the tissues and less discomfort
to the patient.[8]
Becker et al. reported 93.3% of the survival of implants
when placed at the time of extraction.[9,10] However, it is
well recognized that the extraction of a tooth can cause a
reduction in bone volume, especially in the labial/buccal
and marginal areas.[11] Socket preservation techniques
may minimize remodeling and resorption; however,
they cannot eliminate them completely. Besides, BPP is
an alternative to traditional socket preservation.
Surgical intervention in the BPP technique includes
bone graft placement outside rather than inside the
socket.[11] However, these bone substitutes implanted
into extraction sockets prevent labial or buccal bone
resorption and counteract the changes in the esthetic
zone and maintain the soft‑tissue contour while
permitting natural socket healing.
Low availability and donor‑site morbidity of autogenous
bone grafts have patented the use of alternative products,
such as allogeneic and alloplastic materials. Bio‑Oss is a
highly porous structure with a large contact surface area,
which in turn promotes more capillaries in the growth,
migration, and proliferation of osteoblasts.[12] On the
other hand, PerioGlas helps in osteoconduction, and
their ability to bond to soft and osseous tissues makes
it unique when compared to other alloplastic materials
available.[13] The current study evaluated the efficacy of
synthetic bioactive glass (allograft) and demineralized
bovine bone matrix graft (Bio‑Oss) in the immediate
implant site. The outcome of treatment was evaluated
both clinically and radiographically for 1 year.
The present study evaluated both the FM plaque index
and plaque index of the IMP site. Comparing the mean
plaque index values in both the groups at 3 months,
6 months, and 1 year, respectively, showed that although
there was a decrease in plaque index values in the
follow‑up period. This indicates that this treatment
Journal of Dental Implants | Volume 10 | Issue 2 | July-December 2020 97
procedure was effective using synthetic allograft and
xenograft, respectively, in the immediate implant site.
However, there was no statistically significant difference
between either the groups. This could possibly be due to
P the better oral hygiene routine that was maintained by
0.62 the patients in both the groups. Similarly, a study done
by Vishwambaran et al.[14] compared the mean plaque
0.87 index in the FM as well as the immediate implant site.
The results showed a decrease in the mean value of
0.31 the plaque index from baseline to 12 months, and this
reduction was not statistically significant (P > 0.05).
The gingival index is another parameter for evaluating
both the peri‑implant mucosa and oral hygiene of the
participants. In the current study, the results suggested
the following: first excellent healing postoperatively
with both allograft and xenograft, and second, mild
gingivitis and good peri‑implant tissue with no signs
of inflammation.   However, a comparison of the mean
gingival index between Groups A and B showed no
statistically significant difference. This could be due
to the good oral hygiene routine maintained by the
participants. Vishwambaran et  al. reported that the
mean gingival index for Group A was 0.901 and that for
Group B 0.845 at the end of the 12‑month period. Besides,
gingival indices showed intermittent fluctuations
without any statistical significance (P > 0.05).[14]
Peri‑implant probing is an important parameter for the
evaluation of periodontal health in the maintenance
phase of periodontal therapy. The current study
evaluated the probing depth at buccal, lingual, mesial,
and distal sites for both Groups A and B. The present
study showed a stable probing depth of <2 mm. This
suggests that the implant site showed no signs of
peri‑implantitis and all the patients had good periodontal
health. A study conducted by Vishwambaran et  al.
reported that the probing depths have increased because
the implants were placed 1 or 2 mm below the level of
the alveolar crest.[14]
The present study evaluated radiographically for bone
resorption at the mesial and distal sites of the implant.
The amount of bone resorption was measured from the
crestal bone level to the implant crest module at the
mesial and distal sites using CorelDRAW software. The
results showed a significant decrease in bone height,
indicating bone remodeling around the immediate
implant site. However, further studies with larger sample
sizes are recommended to obtain a significant statistical
difference between the two groups.
Even though immediate implant placement is a very
reliable and predictable procedure, to attain excellent
osseointegration and primary stability, the jumping
distance/voids between the implant and the buccal
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Daniel, et al.: Bone grafts in immediate implant site
cortical plates need to be filled with a graft material.
Buccal preservation techniques have had an added
advantage as they do not interfere with the natural
physiological healing of the socket and allow immediate
implant placement by maintaining the soft‑tissue
contour. In addition, it is cost‑effective since augmenting
the labial plate externally requires less graft material
than intrasocket grafting.[15] In the current study, the
success of all the thirty implants at the end of 1 year
was 100% with no sign of clinical mobility or infection
both clinically and demographically. Thus, concerning
the efficacy of synthetic allograft and bioresorbable
xenograft, both showed excellent osseointegration
around the immediate implant site. Moreover, there was
no donor site morbidity, and overall, it was cost‑effective,
maintained excellent esthetics, and shortened edentulous
period.
CONCLUSION
Despite the limitations of this clinical trial, our study
proved that both the synthetic allograft (PerioGlas) and
xenograft (Bio‑Oss) have equal potential in bone forming
around the implant in various augmentation procedures.
However, further research studies with more emphasis
on the current topic are recommended.
Acknowledgment
We would like to thank the authors who viewed and
agreed for submission and specially acknowledge
Dr. Neelakamal Hallur, Dr. Ashwini, Dr. Shereen, and
Dr. Kapil.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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