## 2 Case Report
### Surgical Phase  
The choice of SB(r) was also driven by its specific properties with regard to mechanical resistance [11] and tenacity to screws. There could be no breakage or loss of stability in the interior bone without a risk of cracks, which would cause mobility and improper healing of the graft into the maxillary defect. After a careful evaluation, it was decided to proceed grafting only the patient's right side.  
Figure 1: Initial situation of the pre-maxilla: (**A**) soft tissue of the dedentulous area, (**B**) 3D CAD reconstruction of the upper jaw atrophy.  
Figure 3: (**A**) Virtual planning of the surgical rehabilitation. (**B**) Stereolithographic model of the 3D resin reconstruction.  
Figure 2: Cone beam computed tomography (CBCT) analysis before surgical treatment showed severe bone atrophy in the pre-maxilla area: (**A**) sagittal view, (**B**) coronal view and (**C**) axial view.  
Surgery was performed according to standard protocols. After the appropriate anesthetic procedures, a crestal incision and a mucoperiosteal flap reflection were prepared. Thanks to the correct releasing incision, these provided ease of access for the operation taking place (Figure 4A). The SmartBone(r) on Demand(tm) graft was easily placed on the defect and tightly fixed with two osteosynthesis screws (Figure 4B). A resorbable membrane was then attached, and the mucoperiosteal flap was repositioned in its original position and sutured to cover the heterologous bone block (Figure 4C).  
In the postoperative phase, the patient was prescribed systemic antibiotics (tetracyclines) and anti-inflammatory and analgesics for 7 days. The patient was placed on a regular follow-up and control protocol. A check-up after surgery showed that everything was proceeding well: a CBCT showed a well-adapted integrated graft with signs of new bone formation already after 2 months (Figure 5).  
After a healing period of 8 months, the soft tissue and radiographic findings were clinically good and showed good bone regeneration, suitable for implant placement.  
The exemplificative images reported in Figure 6 show evidence of successful integration of the bone graft and its progressive remodeling.  
Figure 4: Surgical phase: (**A**) skeletonization of the defect area, (**B**) graft positioning and screws fixation and (**C**) soft tissue sutures.  
Figure 5: CBCT scan at 2 months after the surgical operation. It shows a good initial integration and stability of the SB® custom graft. (**A**) Sagittal view, (**B**) coronal view and (**C**) axial view.  
Figure 6: Axial view of the CBCT slide after 8 months following surgery. It shows good osteointegration at the bone material into the recipient site. Good bone density is shown as well. (**A**) Axial view after 8 months of the surgical operation. (**B**) Axial view before the surgical operation.  
Seven implants were placed (Figures 7 and 8), and no post-operative complications were recorded at the time of the implant placement surgery.  
Following implant placement, bone samples were harvested for histological analysis. The exemplificative histology segment presented in Figure 9 shows SmartBone(r) vs newly formed tissue (H/E staining method): a thin trabecular bone with a mature lamellar structure is evident, and no reactions to foreign bodies are present.  
Figure 8: Surgical implants placement. (**A**) Bone quality after the re-opening, (**B**) positioning of seven implants and (**C**) suture of the soft tissue.  
Figure 7: Surgical planning of the implants’ placement.  
Figure 9: Histology (200\(\times\)) segment: (**A,B**) show substitution of the SB®, and the osteogenesis has formed a lamellar bone with cement lines; a lot of osteocytes inside the lacunae and a good angiogenesis are evidenced.