**3. Results**

#### **3.1. Experiment 1 in rats**

#### *3.1.1. Bone mineral density evaluation*

Non statistically significant differences were found in BMC and BMD of tibiae filled with SBM and BO (**Figure 1**), whereas SBM and BO exhibited higher BMC and BMD than the control group (**Figure 1**).

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**Figure 1.** Total skeleton bone mineral content (A) and bone mineral density (B) in control, Bio-Oss (BO) and synergy bone matrix groups (SBM) (\*p < 0.05 vs. control).

#### *3.1.2. Histological analysis*

the rendered treatment. Images of the histological sections were captured by a digital camera (Olympus DP 10; Olympus Optical, Tokyo, Japan) connected to a light microscope (Olympus CX 31; Olympus Optical). Digital images were saved for static histomorphometrical analysis (experiment 2) using Image-Pro Plus 4.5 software. The following criteria were used to standardize the analysis: the total area (TA) to be analyzed was delineated on the composite image. The TA (mm<sup>2</sup>

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corresponded to the area of the mandible where the surgical defect was previously created, and it was considered 100% of the area to be analyzed. The newly formed bone area (NFBA) and the remaining graft particles area (RGPA) were then delineated. Both, NFBA and RGPA, were located entirely within the confines of the TA. The NFBA and RPGA were also calculated in mm<sup>2</sup>

the percentage calculated according to the following formula: 100-NFBA/TA. Values obtained from each animal were used to calculate the means and SD of each control and experimental group. We evaluated bone volume (% BV/TV): the percentage of cancellous bone within the total measured area and the percentage of remaining particles (% RP/TV) of either SBM or BO.

Biomechanical measurements were performed using a three-point bending test (Instron 4411, Universal Testing Materials). The equipment consists of a load frame in which is placed the material to be test (test tube) and a control console that provides calibration controls, programming, and test operation. The installed load cell allows the measurement of compressive forces exerted on the crosshead specimen. IX Series software was used to pick up data analysis of testing bone material. Control, SBM, and BO specimens were cleaned of soft tissues and cut in squares of 20 × 20 mm in the area where the bone defect was done. Bones were weighed and measured. Then they were placed one by one on the rollers, and the bone fracture was performed to evaluate elastic modulus (Mpa) and shear modulus (Mpa). Compression test

Results were expressed as mean ± standard deviation (SE). Data were analyzed using parametric tests according to data distribution and "a posteriori" tests. Data were analyzed using one-way analysis of variance (ANOVA). The Bonferroni multiple comparisons test was performed when significant differences were found. Student's t-test for independent samples was used to compare both bone grafts at each end point. Statistical analyses were performed using SPSS version 19 (SPSS Inc., Chicago, IL, USA). p < 0.05 was considered significant.

Non statistically significant differences were found in BMC and BMD of tibiae filled with SBM and BO (**Figure 1**), whereas SBM and BO exhibited higher BMC and BMD than the control

).

*2.1.5. Biomechanical tests in rabbits*

*2.1.6. Statistical analysis*

**3. Results**

**3.1. Experiment 1 in rats**

group (**Figure 1**).

*3.1.1. Bone mineral density evaluation*

was performed to evaluate compressive strength (KgF/mm<sup>2</sup>

)

and

Cross-sections of tibiae showed remaining particles of each bovine bone graft in the area of the CSBD. Multiple particles of either SBM or BO, of different shapes and sizes, surrounded by laminar bone tissue were observed in the bone medullary space (**Figure 2A**, **B** and **C**). This finding indicates that both bone substitutes were osteoconductive. Proper bone healing was observed in tibiae from both groups. No signs of inflammation were observed; this result suggests biocompatibility (**Figure 2A**, **B** and **C**). After 4 weeks, blood vessels with small angiogenesis and revascularization foci formed in the CSBD implanted with either SBM or BO. The samples also showed mature Haversian systems forming a thin interface within the NBF represented by bone growth and surfaces covered by osteoblasts and fibroblast-like cells surrounding the bone grafts, which implied active osteogenesis. The present study suggests that the bovine bone graft SBM presented similar properties of biocompatibility without inflammatory signs to that of BO. Moreover, SBM also exhibited similar osteoconductive properties to BO, allowing a normal bone formation surrounding the particles.

#### **3.2. Experiment 2 in rabbits**

#### *3.2.1. Histological analysis*

As expected, control rabbits did not exhibited NBF at any of the studied times. Instead histological samples exhibited normal development of fatty bone marrow with occasional remnants of hematopoiesis foci in the site of the CSBD (**Figure 3A**, **D** and **G**). CZBD filled with each of the bovine bone grafts did not evidenced "foreign body" reaction at any of the studied times. Bone healing over time was accompanied by a progressive inflammatory response consistent with the expected histological stages of repairing. In addition, SBM and BO groups presented NBF characterized by trabecular bone growth and the presence of osteoblasts and fibroblastlike cells (**Figure 3**). Both samples exhibited blood vessel formation with small angiogenesis and revascularization foci and Haversian mature systems the implanted grafts, forming a

*3.2.2. Histomorphometrical analysis*

*3.2.3. Biomechanical tests*

the control group.

Histomorphometrical analysis showed an increase in new bone formation (% BV/TV) that was time dependent for both bone grafts compared to the control group (p < 0.05) (**Figure 4A**). A time dependent reduction in the percentage of remnant particles of each device (% RP/TV) was also observed. As control group was not filled with any of the grafts, RP/TV remained in 0. Since the size of the granules of SBM was bigger than that of BO, it is speculated that this

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Both grafting materials exhibited a significant increase in elastic modulus, shear modulus, and compressive strength at 4, 8, and 12 weeks (**Figure 5A**, **B**, and **C**). This finding suggests that the biomechanical properties of the newly formed bone were equivalent for the two grafts evaluated. Moreover, the quality of the newly formed bone was superior to that presented by

**Figure 4.** New bone formation (A). Histomorphometrical analysis of rabbit mandible showed an increase in bone formation in the critical sized bone defects filled with synergy bone matrix (SBM) or Bio-Oss (BO), \*p < 0.05 by one-way ANOVA, followed by Bonferroni multiple comparisons test. Remnant particles of each device (B). Histomorphometrical analysis of rabbit mandible showed a time-dependent decrease in the remaining particles in the critical sized bone

**Figure 5.** Biomechanical tests. The new bone formed in the critical sized bone defects filled with synergy bone matrix (SBM) and Bio-Oss (BO) presented better quality than the control group exhibited by higher elastic modulus (A), shear modulus (B) and compressive strength (C). \*p < 0.05 by one-way ANOVA, followed by Bonferroni multiple comparisons test.

defects filled with SBM and BO, p = N.S between SBM and BO by one-way ANOVA.

factor contributed to the low percentage of RP/TV observed for BO (**Figure 4B**).

**Figure 2.** Histological evaluation in rats. Photomicrography of the critical-sized bone defects at 10× or 40× magnification and stained with Hematoxylin-Eosin. A: Control group exhibited the presence of fibrous tissue. B: Critical-sized bone defect filled with synergy bone matrix (SBM). C: Critical-sized bone defect filled with Bio-Oss (BO). Black arrows indicate SBM or BO particles; NB: new bone formation surrounding the particles.

**Figure 3.** Histological evaluation in rabbits. Photomicrography of the critical-sized bone defects (CSBD) at 4×, 10× or 40× magnification and stained with Hematoxylin-Eosin. Control group exhibited the presence of fibrous tissue at 4 (A), 8 (D) and 12 (G) weeks. CSBD filled with synergy bone matrix (SBM) and Bio-Oss (BO) showed new bone formation surrounding each particle at 4, 8 and 12 weeks. B, E and H: SBM at 4, 8 and 12 weeks. C, F and I: BO at 4, 8 and 12 weeks. Black arrows indicate SBM or BO particles; NB: new bone formation surrounding the particles.

thin interface with the bone forming tissue. The presence of traces of bone substitutes and the formation of blood vessels with small foci of angiogenesis and revascularization was also evident. Moreover, we observed the presence of mature Haversian systems around the bone grafts (**Figure 3**). These findings indicate that SBM and BO are osteoconductive and histologically substantially equivalent.

#### *3.2.2. Histomorphometrical analysis*

Histomorphometrical analysis showed an increase in new bone formation (% BV/TV) that was time dependent for both bone grafts compared to the control group (p < 0.05) (**Figure 4A**). A time dependent reduction in the percentage of remnant particles of each device (% RP/TV) was also observed. As control group was not filled with any of the grafts, RP/TV remained in 0. Since the size of the granules of SBM was bigger than that of BO, it is speculated that this factor contributed to the low percentage of RP/TV observed for BO (**Figure 4B**).

#### *3.2.3. Biomechanical tests*

**Figure 3.** Histological evaluation in rabbits. Photomicrography of the critical-sized bone defects (CSBD) at 4×, 10× or 40× magnification and stained with Hematoxylin-Eosin. Control group exhibited the presence of fibrous tissue at 4 (A), 8 (D) and 12 (G) weeks. CSBD filled with synergy bone matrix (SBM) and Bio-Oss (BO) showed new bone formation surrounding each particle at 4, 8 and 12 weeks. B, E and H: SBM at 4, 8 and 12 weeks. C, F and I: BO at 4, 8 and 12 weeks.

**Figure 2.** Histological evaluation in rats. Photomicrography of the critical-sized bone defects at 10× or 40× magnification and stained with Hematoxylin-Eosin. A: Control group exhibited the presence of fibrous tissue. B: Critical-sized bone defect filled with synergy bone matrix (SBM). C: Critical-sized bone defect filled with Bio-Oss (BO). Black arrows

indicate SBM or BO particles; NB: new bone formation surrounding the particles.

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thin interface with the bone forming tissue. The presence of traces of bone substitutes and the formation of blood vessels with small foci of angiogenesis and revascularization was also evident. Moreover, we observed the presence of mature Haversian systems around the bone grafts (**Figure 3**). These findings indicate that SBM and BO are osteoconductive and histologi-

Black arrows indicate SBM or BO particles; NB: new bone formation surrounding the particles.

cally substantially equivalent.

Both grafting materials exhibited a significant increase in elastic modulus, shear modulus, and compressive strength at 4, 8, and 12 weeks (**Figure 5A**, **B**, and **C**). This finding suggests that the biomechanical properties of the newly formed bone were equivalent for the two grafts evaluated. Moreover, the quality of the newly formed bone was superior to that presented by the control group.

**Figure 4.** New bone formation (A). Histomorphometrical analysis of rabbit mandible showed an increase in bone formation in the critical sized bone defects filled with synergy bone matrix (SBM) or Bio-Oss (BO), \*p < 0.05 by one-way ANOVA, followed by Bonferroni multiple comparisons test. Remnant particles of each device (B). Histomorphometrical analysis of rabbit mandible showed a time-dependent decrease in the remaining particles in the critical sized bone defects filled with SBM and BO, p = N.S between SBM and BO by one-way ANOVA.

**Figure 5.** Biomechanical tests. The new bone formed in the critical sized bone defects filled with synergy bone matrix (SBM) and Bio-Oss (BO) presented better quality than the control group exhibited by higher elastic modulus (A), shear modulus (B) and compressive strength (C). \*p < 0.05 by one-way ANOVA, followed by Bonferroni multiple comparisons test.

### **4. Case report**

A 54-year-old female patient was referred to the Department of Clinical Operative and Prosthesis II, Dental School, University of Buenos Aires, Buenos Aires, Argentina, for the rehabilitation of the edentulous maxilla. Radiographic and cone beam computed tomography (CBCT) exhibited severe atrophy in the posterior region of the maxilla (**Figure 6**). The medical history did not reveal any systemic disease, and the patient did not reported to be under any medication. The patient aimed to rehabilitate the upper jaw with a fixed implant-supported prosthesis. The proposed treatment plan was divided in two stages. The first stage included the confection of a complete upper denture, as well as a surgical and radiological stent, and the reconstruction of the posterior maxillary alveolar ridge. The second stage, after 6 months, consisted in the placement of four dental implants in the posterior maxilla. All the clinical procedures were conducted under the patient's written informed consent. The purpose of this clinical case report was to provide clinical evidence of the efficacy of a new bovine bone graft

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The bilateral sinus elevation procedure was performed using the technique previously described by Tatum [42]. Briefly, after anesthetized with infiltrative local carticaine hydrochloride 4% with adrenaline 1:100.000 (Totalcaína Forte, Microsules Bernabó, Argentina), a mucoperiosteal flap was elevated with releasing vertical incisions. Once exposed the buccal wall of the remaining alveolar process and the anterolateral wall of the Highmore antrum, a surgical stent was used to locate the lateral window. An oval osteotomy was performed with high speed handpiece and a round diamond bur under copious irrigation with saline, leaving a "bone island," in the lateral wall of the sinus, attached to the Schneider membrane (**Figure 7**). This fragment of bone was then turned medially and positioned toward the sinus floor. The sinus membrane was then elevated across the floor and up the medial wall. A bilateral guided bone regeneration procedure was performed using a mixture of SBM. The graft was covered with a rebsorbable collagen membrane (BioCollagen, Bioteck, Italy). Finally, the flap was repositioned and sutured without tension. The patient was instructed to perform oral hygiene and to rinse 2 times a day during 7 days with chlorhexidine digluconate 0.12% for disinfection of the surgical wound. Amoxicillin-clavulanate 875 mg was prescribed twice a day for 7 days, and 500 mg of naproxen was administered every 8-12 hours for 5 days to control postoperative pain. Soft diet was also recommended. The sutures were removed after 7 days. CBCT scans and panoramic x-rays were obtained preoperative, 6 months after stage 1, and 4 months after stage 2. A biopsy of each treated area was taken with a trephine bur during the implant placement surgery.

**Figure 7.** Sinus elevation surgery and guided tissue regeneration. A: Elevation of a mucoperiosteal flap. B: Oval osteotomy and "bone island" in the lateral wall of the sinus attached to the Schneider membrane. C: Synergy bone matrix (SBM). D, E: Placement of SBM for guided bone regeneration. F. The graft was covered with a rebsorbable collagen membrane.

in the bone healing process.

**4.1. Sinus elevation surgery and guided tissue regeneration**

**Figure 6.** Preoperative diagnostic images. All images exhibited a dramatic loss of bone in the upper left and right maxilla. A: Panoramic X-ray showing edentulous maxilla and mandible. B, C. 3-D reconstruction of the left (B) and right (C) maxilla with the surgical stent. D, E: coronal cut from a cone beam computed tomography scan from the left (D) and right (E) maxilla.

prosthesis. The proposed treatment plan was divided in two stages. The first stage included the confection of a complete upper denture, as well as a surgical and radiological stent, and the reconstruction of the posterior maxillary alveolar ridge. The second stage, after 6 months, consisted in the placement of four dental implants in the posterior maxilla. All the clinical procedures were conducted under the patient's written informed consent. The purpose of this clinical case report was to provide clinical evidence of the efficacy of a new bovine bone graft in the bone healing process.

#### **4.1. Sinus elevation surgery and guided tissue regeneration**

The bilateral sinus elevation procedure was performed using the technique previously described by Tatum [42]. Briefly, after anesthetized with infiltrative local carticaine hydrochloride 4% with adrenaline 1:100.000 (Totalcaína Forte, Microsules Bernabó, Argentina), a mucoperiosteal flap was elevated with releasing vertical incisions. Once exposed the buccal wall of the remaining alveolar process and the anterolateral wall of the Highmore antrum, a surgical stent was used to locate the lateral window. An oval osteotomy was performed with high speed handpiece and a round diamond bur under copious irrigation with saline, leaving a "bone island," in the lateral wall of the sinus, attached to the Schneider membrane (**Figure 7**). This fragment of bone was then turned medially and positioned toward the sinus floor. The sinus membrane was then elevated across the floor and up the medial wall. A bilateral guided bone regeneration procedure was performed using a mixture of SBM. The graft was covered with a rebsorbable collagen membrane (BioCollagen, Bioteck, Italy). Finally, the flap was repositioned and sutured without tension. The patient was instructed to perform oral hygiene and to rinse 2 times a day during 7 days with chlorhexidine digluconate 0.12% for disinfection of the surgical wound. Amoxicillin-clavulanate 875 mg was prescribed twice a day for 7 days, and 500 mg of naproxen was administered every 8-12 hours for 5 days to control postoperative pain. Soft diet was also recommended. The sutures were removed after 7 days. CBCT scans and panoramic x-rays were obtained preoperative, 6 months after stage 1, and 4 months after stage 2. A biopsy of each treated area was taken with a trephine bur during the implant placement surgery.

**Figure 7.** Sinus elevation surgery and guided tissue regeneration. A: Elevation of a mucoperiosteal flap. B: Oval osteotomy and "bone island" in the lateral wall of the sinus attached to the Schneider membrane. C: Synergy bone matrix (SBM). D, E: Placement of SBM for guided bone regeneration. F. The graft was covered with a rebsorbable collagen membrane.

**Figure 6.** Preoperative diagnostic images. All images exhibited a dramatic loss of bone in the upper left and right maxilla. A: Panoramic X-ray showing edentulous maxilla and mandible. B, C. 3-D reconstruction of the left (B) and right (C) maxilla with the surgical stent. D, E: coronal cut from a cone beam computed tomography scan from the left (D) and

A 54-year-old female patient was referred to the Department of Clinical Operative and Prosthesis II, Dental School, University of Buenos Aires, Buenos Aires, Argentina, for the rehabilitation of the edentulous maxilla. Radiographic and cone beam computed tomography (CBCT) exhibited severe atrophy in the posterior region of the maxilla (**Figure 6**). The medical history did not reveal any systemic disease, and the patient did not reported to be under any medication. The patient aimed to rehabilitate the upper jaw with a fixed implant-supported

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right (E) maxilla.

**4. Case report**

During the first surgical stage, a postoperative follow-up 7 days after the procedure revealed that the edges of the flap wounds faced each other, and there were no signs of dehiscence or inflammation. The patient did not report any discomfort, pain, or inflammation of the treated areas. The postoperative CBCT, taken 6 months after this surgery, exhibited an increase of 10.7 mm and 10.8 mm in the height of the alveolar crest and an increase in the alveolar crest width of 3.5 mm and 2.8 mm in the right and left side, respectively (**Figure 8**). Six months after the sinus lift surgery, dental implants were placed in the areas that received the bone graft (stage 2). Dental implants in the areas grafted achieved primary stability, indicating that there was an accurate bone quality after the placement of the bone graft. Consistent with the digital imaging findings, histological evaluation of the bone samples retrieved during the implant surgery revealed that SBM particles were osteoconductive. All particles were surrounded by new bone formation (**Figure 9**). There were fibro-angiogenic and fibrous areas associated to

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**Figure 10.** Post-dental implant placement diagnostic images. All images showed bone gain in both sides of the maxilla that persisted after the placement of dental implants. A: Panoramic X-ray from a CBCT showing the increase in alveolar bone height and dental implants on the right and left side. B: Reconstruction of the left and right maxilla with the

surgical stent. C, D: Coronal cut from a CBCT scan from the left (C) and right (D) maxilla.

**Figure 8.** Postoperative CBCT (6 months after the sinus elevation surgery). A, B, C: There was an increase of 10.7 mm and 10.8 mm in the height of the alveolar crest, and an increase in the alveolar crest width of 3.5 mm and 2.8 mm in the right and left side, respectively.

**Figure 9.** Histological evaluation of the areas grafted with synergy bone matrix (SBM) at 4×, 10× or 20× magnification and stained with Hematoxylin-Eosin. New bone formation surrounding each particle was observed in right (A, B) and left (C, D) grafted sinus. Black arrows indicate SBM particles. NB: new bone formation.

During the first surgical stage, a postoperative follow-up 7 days after the procedure revealed that the edges of the flap wounds faced each other, and there were no signs of dehiscence or inflammation. The patient did not report any discomfort, pain, or inflammation of the treated areas. The postoperative CBCT, taken 6 months after this surgery, exhibited an increase of 10.7 mm and 10.8 mm in the height of the alveolar crest and an increase in the alveolar crest width of 3.5 mm and 2.8 mm in the right and left side, respectively (**Figure 8**). Six months after the sinus lift surgery, dental implants were placed in the areas that received the bone graft (stage 2). Dental implants in the areas grafted achieved primary stability, indicating that there was an accurate bone quality after the placement of the bone graft. Consistent with the digital imaging findings, histological evaluation of the bone samples retrieved during the implant surgery revealed that SBM particles were osteoconductive. All particles were surrounded by new bone formation (**Figure 9**). There were fibro-angiogenic and fibrous areas associated to

**Figure 8.** Postoperative CBCT (6 months after the sinus elevation surgery). A, B, C: There was an increase of 10.7 mm and 10.8 mm in the height of the alveolar crest, and an increase in the alveolar crest width of 3.5 mm and 2.8 mm in the

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**Figure 9.** Histological evaluation of the areas grafted with synergy bone matrix (SBM) at 4×, 10× or 20× magnification and stained with Hematoxylin-Eosin. New bone formation surrounding each particle was observed in right (A, B) and left

(C, D) grafted sinus. Black arrows indicate SBM particles. NB: new bone formation.

right and left side, respectively.

**Figure 10.** Post-dental implant placement diagnostic images. All images showed bone gain in both sides of the maxilla that persisted after the placement of dental implants. A: Panoramic X-ray from a CBCT showing the increase in alveolar bone height and dental implants on the right and left side. B: Reconstruction of the left and right maxilla with the surgical stent. C, D: Coronal cut from a CBCT scan from the left (C) and right (D) maxilla.

SBM, as well as gradual regression of associated fibrosis. The bone formation pattern was lamellar and trabecular, and the presence of osteoblast at the surface of the trabeculae, as well as osteocytes, was also observed. There were no signs of inflammation or bone sequestrae.

Bone formation begins with the appearance of osteoblasts in the defect area that secretes bone matrix (i.e. collagen); this period is followed by mineralization in order to wrap the implanted

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Bone is a dynamic tissue that undergoes remodeling. Bone remodeling is a coupled process that starts with osteoclastic bone resorption followed by osteoblastic bone formation [45]. In this sense, the osteoclastic resorption of the graft is affected by both, the particle size as well

Initially, once the graft material is place, it suffers osteoclastic bone resorption followed by bone formation by osteoblastic action. The porosity of the particles enhances new bone formation by allowing the migration and proliferation of osteoblast and mesenchymal cells [46]. In addition, the microporosity of the particles is believed to enhance ionic exchange with body fluids [46]. This characteristic allows each particle of SBM to serve as a 3-D scaffold, in which osteoblast and osteoprogenitor cells migrate and form bone. Consistent with this, during the first period (4 weeks), we observed active osteogenesis evidencing by the presence of bone surfaces covered by osteoblasts around the implanted bone grafts and the formation of mature haversian systems. Toward the end of the experience, the collagen fibers were replaced by mature bone that filled the CSBD region. These findings indicate that the process

It is important to emphasize the quantity and quality of bone formed after placing a bone graft. On this regard, the increase in rat tibiae BMD indicates that the amount of bone increased in the CSBD filled with SBM or BO. In addition, biomechanical test performed in rabbit mandible exhibited an increase in all parameters, suggesting an enhanced quality of the newly

Chackarti et al. observed, in a histomorphometric and micro-CT analysis, that granules from different sizes (small or large), produced the same pattern of bone formation: the bone surrounding the graft connects and produces a network of "bone bridges" among the graft particles [47]. The two used bone grafts had a similar granulometry: 1 to 2 mm for BO and 0.84 to 2 mm for SBM. Although BO and SBM are available in small granules as well as blocks, these were considered too small or too large for the rabbit experimental model used. In the present study, the volume of remaining bone graft particles was similar, and the biomechanical results did not show differences between SBM or BO, suggesting that the quality of the bone

The loss of teeth in the posterior area of the maxilla leads to adverse consequences on masticatory function and occlusal balance. These outcomes negatively results in psychophysical conditions associated with temporomandibular joint and muscle diseases. A frequent problem in oral rehabilitation with implant-supported prostheses in the posterior maxilla is the lack of bone volume associated with alveolar ridge resorption or maxillary sinus pneumatization [48]. The reabsorption of the alveolar bone, adjacent to the floor of the maxillary sinus, may be aggravated by the increase in osteoclastic activity that originates in the periosteum of Schneider's membrane, after tooth loss, due to the absence of osteogenesis normally stimulated by the functional load on the bone. In this sense, the bone volume is limited due to the

of bone regeneration induced by SBM was similar to that induced by BO.

graft material [44].

formed bone.

formed was similar for both products.

as the composition and porosity of the material.

Postoperative 4-month control digital images exhibited osseointegration of the implants (**Figure 10**). No peri-implant radiolucencies were observed. The regenerated bone gain by the graft placement in both sides was preserved (**Figure 10**). Clinical assessment of the dental implants did not exhibited mobility of the implants, and a solid-deaf sound when performing percussion tests showed proper bone healing. The patient did not report pain, and there was no leakage of purulent material or signs of inflammation. In addition, the grafted bone presented the similar density than the perisinusal bone at both sides.
