Evaluation of Immediately Placed Ultra-wide Diameter Implant Placed in Mandibular Molars
Phase: NA
Conditions: Dental Implants
Sponsor: Abdelrahman Elshahawy

3/7/2021 
 
 
 
EVALUATION OF 
IMMEDIATELY PLACED 
ULTRA WIDE DIAMETER 
IMPLANT PLACED IN 
MANDIBULAR MOLARS. 
     
 
Abdelrahman karam gad. 
     

 
 
 
 
 
 
 
 
Faculty of Dentistry 
Department of Oral and Maxillofacial Surgery 
 
 
 
 
 
 
 
Student Code No. 
Protocol for M. Sc. Degree
 
In Oral and Maxillofacial Surgery 
Academic Year 2020 – 2021 
Name of Candidate: Abdelrahman Karam Gad 
Title: 
English Title:  EVALUATION OF IMMEDIATELY PLACED ULTRA 
WIDE 
DIAMETER 
IMPLANT 
PLACED 
IN 
MANDIBULAR MOLARS. 
 
Keywords:   Dental implant, Immediate placement, Ultra-wide. 
 
 
Supervision Committee: 
1- Prof. Dr. Ragab Shaaban Hassan 
Professor of Oral and Maxillofacial Surgery 
Oral and Maxillofacial Surgery Department 
Faculty of Dentistry 
Alexandria University 
2- Dr. Gaafar Nabil Ahmed El Halawani 
Lecturer of Oral and Maxillofacial Surgery 
Oral and Maxillofacial Surgery Department 
Faculty of Dentistry 
Alexandria University 
 
 
 
 
 
 

 
 
 
 
 
Role of Supervisors 
 
1- Prof. Dr. Ragab Shaaban Hassan 
Supervise the clinical work. 
Manage an accurate case selection. 
Help the student in interpreting results and revising the thesis. 
 
2- Dr. Gaafar Nabil Ahmed El Halawani  
Supervise the clinical work. 
Manage an accurate case selection. 
Help the student in interpreting results and revising the thesis. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
CONTENTS 
Contents          
 
 
 
 
 
 
 
Page  
 
 
− ABSTRACT                                                     
1 
− INTRODUCTION                                                                                 2 
− AIM OF THE STUDY                                                                         5 
− PLAN OF STUDY                                                                            
6 
− STATISTICAL ANALYSIS                                                                 14 
− ETHICAL CONSIDERATIONS                                                          15 
− DURATION OF THE STUDY                                                             16 
− ESTIMATED BUDGET                                                                       17 
− PROBLEMS ANTICIPATED                                                               18 
− PUBLICATION POLICY                                                                     19 
− REFERENCES                                                                                      20 
 
 
 
 
 

 
 
1
 
 
 
 
ABSTRACT 
Background: Ultra-wide-diameter implants (7 mm to 9 mm diameter) are 
gaining favor for immediate placement in the posterior area because they allow 
for increased engagement of molar socket walls, reduce the need to bone graft 
and provide better stress distribution under the high occlusal loads in the 
posterior area. 
Aim of this study: To evaluate both the clinical and radiographical outcome on 
osteointegration and peri-implant bone density when using ultra wide diameter 
implant placed immediately in molar extraction socket.  
Plan of the study: 12 implants for 12 patients will be immediately placed in 
fresh extracted molar sockets without flap or bone grafts. After six months, 
cement retained crown will be loaded to the implant. Clinical and radiographic 
parameters will be evaluated.  
Results: Will be statistically analyzed using the Statistical Package for Social 
Science (SPSS) software version 20.0. 
Keywords: dental implant, immediate placement, ultra-wide. 
 
 

 
 
2
 
 
 
INTRODUCTION 
Alveolar bone undergoes dimensional changes vertically and 
horizontally after tooth extraction as a result of periodontal loss and bundle 
bone resorption in the tooth socket leading to reduction of bone volume that 
affects negatively the dental implant placement and the restorative treatment 
functionally and esthetically.(1)  
The first year following tooth loss in premolar and molar area, up to 50% 
ridge width reduction occurs, where two-thirds of the total reduction occur 
within the first three months’ post extraction.(2)  
To overcome these unfavorable changes, immediate implant placement 
is recommended at the time of tooth removal for less buccolingual bone 
reduction and wider crest compared to the delayed implant placement.(3)  
However, Immediate implant placement in molar extraction socket is 
more critical unlike in single root sockets, this is due to many factors such as 
complex anatomy of molar roots with larger socket dimensions and also the 
high mechanical forces exerted on molar sites.(4)  
Immediate implant as a single surgical procedure has many advantages. 
These advantages include ideal implant positioning,(5, 6) preservation of socket 
bone(7, 8) and shortened treatment time.(9) Furthermore, studies reported less 
amount of bone loss when the implant is placed immediately after tooth 
extraction.(10, 11) 
 
 
The final outcome of immediate placement depends on many important 
factors. These factors include the preservation of the walls of alveolar bone 
during extraction especially the buccal plate, the oral health and hygiene 

 
 
3
 
 
 
conditions, the surgical and prosthetic protocol followed, the surgical technique 
used, the implant position in the socket, the use of bone grafts and the elevation 
approach either flapless or with a flap.(12)  
Successful immediate implant placement is determined by primary 
stability which is an essential factor(13) which is also very challenging in molar 
sockets due to many reasons such as the presence of multiple roots with large 
socket voids, and the anatomical limitations due to presence of maxillary sinus 
and inferior alveolar nerve.(14)  
Implant design including “pitch, width, depth, shape of the thread, and 
crestal module” is an important factor in determining the stress distribution and 
primary stability during osteointegration in immediate loading implants.(15-17)  
Using conventional implant in one of the molar root sockets leads to 
many prosthetic and maintenance complications, it compromises the 
emergence profile which could be avoided by placing the implant into the 
interradicular septum for more prosthetic improvement and long term 
maintenance, However, engaging to the socket septum can lead to inaccurate 
implant site preparation(18) and requires additional bone augmentation to fill the 
residual socket spaces.(19)  
Wider diameter implants in immediate molar implant placement have 
many advantages over the narrow conventional implant. These advantages are 
increasing the contact area engaged the implant with the socket walls and 
interradicular area for better osteointegration and more favorable occlusal 
forces distribution(20) it also enhances the emergence profile and permits using 
wider and stronger prosthetic components.(21)  

 
 
4
 
 
 
Ultra wide dental implants increase primary stability, permit greater 
bone contact and reduce the residual space in molar socket(22) so reduce the 
need to bone graft with a predictable outcome and very little bone loss.(23)  
This technique requires high clinical experience in teeth removal 
atraumatically for bone preservation and site preparation, and also requires a 
careful case selection for a successful treatement.(20)  
Hattingh et al.,(23) concluded that the immediate placement of ultrawide 
diameter dental implant in fresh extracted molar socket following atraumatic 
extraction without any flaps has a predictable outcome esthetically with 
minimal contour changes and accepted stability over time. 
The null hypothesis is that using the ultra-wide implant placed 
immediately after molar extraction has no significant effect on implant stability 
and peri-implant bone density. 
 
 
 
 
 
 
 

 
 
5
 
 
 
AIM OF THE STUDY 
The aim of the study is to evaluate both the clinical and radiographical 
outcome on osteointegration and peri-implant bone density when using ultra 
wide diameter implant placed immediately in molar extraction socket. 

 
 
6
 
 
 
PLAN OF THE STUDY 
Study Design 
The study is a single arm clinical trial.  It will be set up and reported 
according to the CONSORT guidelines. (24) 
The PICO question: Does the immediate placement of ultra wide diameter 
implant in non-restorable mandibular molar socket will enhance primary 
stability and peri-implant bone density? 
Type of patients or population: patients with age range 20-40 years old having 
non-restorable mandibular molar teeth. 
Type of Intervention: immediate placement of ultra wide diameter implant. 
Outcomes: wound healing, socket dimensions, crestal bone loss, implant 
stability and bone density will be the main outcome measures of this study. 
Setting and Location   
Participants will be recruited from the Outpatient Clinic of Alexandria 
University Teaching Hospital and operated in the Oral and Maxillofacial 
Surgery Department, Faculty of Dentistry, Alexandria University. 
Summary Statement 
Sample size was estimated assuming 5% alpha error and 80% study 
power. Tsallarico et al reported that the mean Implant Stability Quotient (ISQ) 
values at baseline for ultra-wide implants was 65.5 ± 7.6 and 78.8 ± 2.8 after 6 
months of implant placement.(25, 26) The sample will be stratified by gender into 
two groups. Sample size was calculated to be 5 patients per group, increased to 
6 patients to make up for loss to follow up. Total sample size = number per 
group × number of groups = 6 × 2 = 12 patients.   
 Software 
Sample size was based on Rosner’s method(27) calculated by Gpower 
3.0.10.(28) All of the obtained data will be collected, statistically analyzed and 
presented in the form of tables, graphs and charts using the IBM Statistical 
Package for Social Science (SPSS) software version 20.0. 
 

 
 
7
 
 
 
Eligibility Criteria  
The criteria for including patients are as follows: 
Inclusion criteria 
• Adult patients ranging from 20-40 years.  
• Adequate bone beyond teeth apices without jeopardizing any anatomical 
structure.(29) 
• Non-restorable mandibular molar teeth.(23)  
• Available bone with adequate width and buccolingual dimensions.  
• Peri-implant bone defect should be 2mm or lesser. 
Exclusion criteria 
• Smokers. 
• Medically compromised patients like uncontrolled diabetes and coagulation 
disorders.  
• Tooth with periapical pathosis or bony defects.(23)  
 
 
 

 
 
8
 
 
 
Study Design 
 
                                  
                                   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients Selection (n=12)
 
Preoperative CBCT
 
Extraction of non-restorable Teeth
 
Peri-implant 
bone density and 
crestal bone loss 
Pain 
Immediate implants placement with ultra wide implants
 
Statistical 
Analysis 
Radiographic 
Evaluation 
Clinical 
Evaluation 
Data Analysis 
(SPSS) 
Data Interpretation 
Swelling 
Wound healing 
Implant 
stability 

 
 
9
 
 
 
 
Materials 
1. (Dentium Superline implant, diameter 7mm, South Korea).  
2. Osstell.  
3. Physiodispenser*** 
Phases  
I. Preoperative Phase 
1- History  
a) Personal history 
Full personal data in details is required; including name, age, gender, 
occupation, address, telephone number. Also, the telephone number of relatives 
and companions. 
b) Past medical history 
History of any medical condition like diabetes, hypertension, drug 
allergy or any medications. 
c) Past dental history 
History of periodontal disease, badly destructed teeth, swelling, trauma, 
failed restorations, any oral pathology and past dental experiences. 
d) Chief complaint 
The 
patient’s 
chief 
complaint, 
desire 
and 
expectations  
will be documented. 
 
 
 
Superline,Dentuim Co,Doublethread,S.L.A surface (sandblasted with large grit and Acid 
etched),Korea 
 Osstell: Osstell, Sweden 
***(COXO | C-SAILOR IMPLANT MOTOR),china. 

 
 
10
 
 
 
2- Clinical examination 
Soft tissue will be examined for any suppuration or discharge, swelling 
or tooth mobility.  
3- Radiographic examination 
Cone-Beam Computed Tomography (CBCT) to evaluate the condition 
and anatomy of tooth, presence of any periapical pathology and  for  
treatment planning. 
II. Surgical Phase 
1- Preoperative patient preparation 
To control infection, antibiotic prophylaxis will be 1 gm 
amoxicillin+clavulanate sixty minutes before operation, according to the 
(INFECTIOUS DISEASES SOCIETY of AMERICA) guidelines. (30)  
2- Operative procedure(22)                                                  
- Surgery will be performed under local anesthesia (Mepecaine-L) with 
1:20000 adrenaline.   
- Atraumatic tooth extraction of molar teeth without any flaps or  
bone removal. 
- Pilot hole will be performed in inter-radicular septum following  
root removal. 
- Osteotomy preparation will be completed up to the planned diameter of 
the implant, which was based on the socket dimensions, followed by 
implant insertion.  
 
 
 

 
 
11
 
 
 
- The implant shoulder should be ensured to be seated 2mm below the 
lowest point of buccal wall and 2mm distance from the buccal wall. 
- A healing abutment will be then connected to the implant and soft tissue 
adaptation as well as void closure will be obtained with suturing and 
hemostatic collagen sponge at the level of the healing abutment. 
3- Postoperative care(23)  
- Patients will be given comprehensive oral hygiene care and postoperative 
instructions, including;  
• Not to rinse for 24 hours after surgery. 
• Cold fomentation for 24 hours only postoperatively. 
• Soft diet, high protein, high calorie diet and fluids for 2 weeks 
postoperatively. 
Postoperative medication 
They will be advised to take the prescribed medications, which include:  
- Amoxicillin 875mg + Clavulanic acid 125mg  every 12 hours for 7 days.  
- Non-Steroidal Anti Inflammatory drugs every 8 hours for 4 days. 
- Chymotrypsin +Trypsin 300 E.A.U every 8 hours for 5 days  
- 0.12% chlorhexidine mouth wash 3 times daily for 2 weeks. 
- Sutures will be removed after one week from surgery. 
 
 
 
 
Augmentin: GalaxoSmithKline,UK 
 
Cataflam: Diclofenac potassium 50mg: Novartis. Switzerland 
 Alphintern: Chemotrypsin 300 E.A.U (14microkatals) +Trypsin 300 E.A.U (5microkatals): 
Amoun Pharmaceutical Co. S.A.E 
  Hexitol: Chlorhexidine 125mg/100ml concentration 0.125%: Arabic drug company, ADCO 

 
 
12
 
 
 
4- Clinical follow-up phase 
Patients will be followed-up both clinically and radiographically for 9 months. 
a) Clinical Evaluation 
1- Postoperative pain.(31) 
-  It will be recorded for each patient after 48 hrs postoperatively, then after 
one week through a 10-point Visual Analogue Scale (VAS) from 0 to 10. 
-  (0-1= None, 2-4= Mild, 5-7= Moderate, 8-10= Severe). 
2- Postoperative swelling.(32) 
-  It will be recorded for each patient after 48 hours postoperatively, then 
after one week through a 10-point scale with 4 parameters will be used. 
-  None (no swelling), light (intraoral, localized to the treated area), 
moderate (extraoral swelling localized to the treated area), and severe 
(extraoral swelling extending beyond the treated area).  
3- Implant stability.(33)  
- It will be measured by implant stability meter (Osstell™) immediately 
postoperative and at 6 months. 
4- Peri-implant probing depth.(34)  
- Pocket probing on dental implants should be conducted with a light force 
(approximately 0.25 N); peri-implant pocket depths should be ≤5 mm. 
 
 
 

 
 
13
 
 
 
b) Radiographic Evaluation(23)  
Immediately postoperative, after 6 months and after 9 months CBCT will 
be requested in order to evaluate: 
1- Peri-implant bone density 
2- Crestal bone loss 
III. Prosthetic phase(22)  
After 6 months of integration, the implant was restored with a cemented 
retained crown. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
14
 
 
 
STATISTICAL ANALYSIS 
All of the obtained data will be collected, statistically analyzed and 
presented in the form of tables, graphs and charts using the IBM Statistical 
Package for Social Science (SPSS) software version 20.0. 
 
 

 
 
15
 
 
 
ETHICAL CONSIDERATIONS 
Participant Safety 
The study subjects will receive both oral and written information about 
the  benefits  and  risks  of  the  interventions,  also  about  the  gained  
advantages compared to the conventional method which are reduced treatment 
plan time, less procedure steps and placement of the implant fixture in an 
optimal axial position threats. 
Follow Up policy 
The patients will be followed up for 6 months in the outpatient clinic of 
Oral and Maxillofacial Surgery Department, Faculty of Dentistry. All patients’ 
personal information will be recorded, and a direct contact with the patient and 
his or her relatives will be established using telephone number in order to 
ensure ease of recall and to provide keen and up to date follow up. 
Informed Consent 
All patients will sign an Informed Consent Form before undergoing the 
operation to ensure and confirm their understanding of the outcome of the 
operation and the risks they might be subjected to during the intervention. 
Research Ethics Committee approval 
The clinical part of the study will be performed after gaining the ethical 
clearance from the Research Ethics Committee, Faculty of Dentistry, 
Alexandria University. 
 
 

 
 
16
 
 
 
DURATION OF STUDY 
Estimated Time: 12 months. 
Tasks/Duration
 
st 
1
 
day
st
1
 
week
1st 
 
Month
th
4
 
Month
th
6
 
Month
 
th
9
 
Month
th
12
 – 
th
9
 
Month
 
Surgical 
Procedure 
√
 
 
 
 
 
 
 
Clinical  
Evaluation 
 
√
 
√
 
√
 
√
 
√
 
 
Radiographic  
Evaluation 
√
 
 
 
 
√
 
√
 
 
Data             
Collection 
 
 
 
 
 
 
√
 
Data             
Analysis 
 
 
 
 
 
 
√
 
Writing 
Manuscript 
 
 
 
 
 
 
√
 
 
 
 
 
 
 
 
 
 

 
 
17
 
 
 
ESTIMATED BUDGET 
Total Budget:  
Item 
Quantity/patient 
Cost /L.E 
Total 
CBCT 
3x12 
400 
14400 
Armamentarium 
 
3000 
3000 
Implant 
1x12 
2400 
28800 
Total 
 
 
46200 
 
  

 
 
18
 
 
 
PROBLEMS ANTICIPATED 
− Microbial interference with osteointegration. 
− Failure to recall the patient for follow up (Follow up dropout). 
  

 
 
19
 
 
 
PUBLICATION POLICY 
The study will be submitted for either national or international journals 
for publication.  
− Abdelrahman Karam Gad. 
− Prof. Dr. Ragab Shaaban Hassan. 
− Dr. Gaafar Nabil Ahmed El-Halawani. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
20
 
 
 
 
REFERENCES 
1. 
Bartee BK. Extraction site reconstruction for alveolar ridge preservation. 
Part 2: membrane-assisted surgical technique. J Oral Implantol 
2001;27:194-7. 
2. 
Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft 
tissue contour changes following single-tooth extraction: a clinical and 
radiographic 12-month prospective study. Int J Periodontics Restorative 
Dent 2003;23:313-23. 
3. 
Covani U, Bortolaia C, Barone A, Sbordone L. Bucco-lingual crestal bone 
changes after immediate and delayed implant placement. J Periodontol 
2004;75:1605-12. 
4. 
Lazzara RJ. Immediate implant placement into extraction sites: surgical 
and restorative advantages. Int J Periodontics Restorative Dent 
1989;9:332-43. 
5. 
Schultz AJ. Guided tissue regeneration (GTR) of nonsubmerged implants 
in immediate extraction sites. Pract Periodontics Aesthet Dent 1993;5:59-
65; quiz 6. 
6. 
Werbitt MJ, Goldberg PV. The immediate implant: bone preservation and 
bone regeneration. Int J Periodontics Restorative Dent 1992;12:206-17. 
7. 
Watzek G, Haider R, Mensdorff-Pouilly N, Haas R. Immediate and 
delayed implantation for complete restoration of the jaw following 
extraction of all residual teeth: a retrospective study comparing different 

 
 
21
 
 
 
types of serial immediate implantation. Int J Oral Maxillofac Implants 
1995;10:561-7. 
8. 
Denissen HW, Kalk W, Veldhuis HA, van Waas MA. Anatomic 
consideration for preventive implantation. Int J Oral Maxillofac Implants 
1993;8:191-6. 
9. 
Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing 
of implant placement after tooth extraction: immediate, immediate-
delayed or delayed implants? A Cochrane systematic review. Eur J Oral 
Implantol 2010;3:189-205. 
10. Vandeweghe S, Nicolopoulos C, Thevissen E, Jimbo R, Wennerberg A, 
De Bruyn H. Immediate loading of screw-retained all-ceramic crowns in 
immediate versus delayed single implant placement. Int J Prosthodont 
2013;26:458-64. 
11. Kinaia BM, Shah M, Neely AL, Goodis HE. Crestal bone level changes 
around immediately placed implants: a systematic review and meta-
analyses with at least 12 months' follow-up after functional loading. J 
Periodontol 2014;85:1537-48. 
12. Mura P. Immediate loading of tapered implants placed in postextraction 
sockets: retrospective analysis of the 5-year clinical outcome. Clin 
Implant Dent Relat Res 2012;14:565-74. 
13. Kan JY, Roe P, Rungcharassaeng K. Effects of implant morphology on 
rotational stability during immediate implant placement in the esthetic 
zone. Int J Oral Maxillofac Implants 2015;30:667-70. 

 
 
22
 
 
 
14. Anitua E, Murias-Freijo A, Flores J, Alkhraisat MH. Replacement of 
missing posterior tooth with off-center placed single implant: Long-term 
follow-up outcomes. J Prosthet Dent 2015;114:27-33. 
15. Sennerby L, Meredith N. Implant stability measurements using resonance 
frequency analysis: biological and biomechanical aspects and clinical 
implications. Periodontol 2000 2008;47:51-66. 
16. Abuhussein H, Pagni G, Rebaudi A, Wang HL. The effect of thread 
pattern upon implant osseointegration. Clin Oral Implants Res 
2010;21:129-36. 
17. Boggan RS, Strong JT, Misch CE, Bidez MW. Influence of hex geometry 
and prosthetic table width on static and fatigue strength of dental implants. 
J Prosthet Dent 1999;82:436-40. 
18. Rodriguez-Tizcareño MH, Bravo-Flores C. Anatomically guided implant 
site preparation technique at molar sites. Implant Dent 2009;18:393-401. 
19. Ortega-Martínez J, Pérez-Pascual T, Mareque-Bueno S, Hernández-
Alfaro F, Ferrés-Padró E. Immediate implants following tooth extraction. 
A systematic review. Med Oral Patol Oral Cir Bucal 2012;17:e251-61. 
20. Smith RB, Tarnow DP. Classification of molar extraction sites for 
immediate dental implant placement: technical note. Int J Oral Maxillofac 
Implants 2013;28:911-6. 
21. Vandeweghe S, De Bruyn H. A within-implant comparison to evaluate the 
concept of platform switching: a randomised controlled trial. Eur J Oral 
Implantol 2012;5:253-62. 

 
 
23
 
 
 
22. Hattingh AC, De Bruyn H, Ackermann A, Vandeweghe S. Immediate 
Placement of Ultrawide-Diameter Implants in Molar Sockets: Description 
of a Recommended Technique. Int J Periodontics Restorative Dent 
2018;38:17-23. 
23. Hattingh A, Hommez G, De Bruyn H, Huyghe M, Vandeweghe S. A 
prospective study on ultra-wide diameter dental implants for immediate 
molar replacement.  2018;20:1009-15. 
24.  David M, G A, F S. CONSORT 2010 Statement: updated guidelines for 
reporting parallel group randomised trials. Trials. 2010 Mar 1;11. 
25. Tallarico M, Xhanari E, Pisano M, Gatti F, Meloni SM. Molar 
replacement with 7 mm-wide diameter implants: to place the implant 
immediately or to wait 4 months after socket preservation?  1 year after 
loading results from a randomised controlled trial. Eur J Oral Implantol 
2017;10:169-78. 
26. Tallarico M, Xhanari E, Pisano M, De Riu G, Tullio A, Meloni SM. Single 
post-extractive ultra-wide 7 mm-diameter implants versus implants 
placed in molar healed sites after socket preservation for molar 
replacement: 6-month post-loading results from a randomised controlled 
trial. Eur J Oral Implantol 2016;9:263-75. 
27. Rosner B. Fundamentals of biostatistics. Nelson Education.
 
2015 . 
28. Universität 
Düsseldorf. 
G*Power. 
2019. 
Available 
at: 
http://www.gpower.hhu.de/. 

 
 
24
 
 
 
29. Antoun H, Cherfane P, Sojod B. Consecutive Case Series of Healed 
Single-Molar Sites Immediately Restored with Wide-Diameter Implants: 
A 1-Year Evaluation. Int J Dent 2016;2016:5645892. 
30. Bratzler, D. W., Dellinger, E. P., Olsen, K. M., Perl, T. M., Auwaerter, P. 
G., Bolon, M. K., Fish, D. N., Napolitano, L. M., Sawyer, R. G., Slain, D., 
Steinberg, J. P., Weinstein, R. A., American Society of Health-System 
Pharmacists, Infectious Disease Society of America, Surgical Infection 
Society, & Society for Healthcare Epidemiology of America (2013). 
Clinical practice guidelines for antimicrobial prophylaxis in surgery. 
American journal of health-system pharmacy : AJHP : official journal of 
the American Society of Health-System Pharmacists, 70(3), 195–283. 
https://doi.org/10.2146/ajhp120568 
31. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for 
measurement of acute pain. Acad Emerg Med 2001;8:1153-7. 
32. Larrazábal C, García B, Peñarrocha M, Peñarrocha M. Influence of oral 
hygiene and smoking on pain and swelling after surgical extraction of 
impacted mandibular third molars. J Oral Maxillofac Surg 2010;68:43-6. 
33. Herrero-Climent M, Santos-García R, Jaramillo-Santos R, Romero-Ruiz 
MM, Fernández-Palacin A, Lázaro-Calvo P, et al. Assessment of Osstell 
ISQ's reliability for implant stability measurement: a cross-sectional 
clinical study. Med Oral Patol Oral Cir Bucal 2013;18:e877-82. 
34. Araujo MG, Lindhe J. Peri-implant health. J Periodontol 2018;89 Suppl 
1:S249-s56.