J Biomater Appl OnlineFirst, published on January 27, 2006 as doi:10.

1177/0885328206054167

Biocompatibility of b-Tricalcium
Phosphate Root Replicas in Porcine
Tooth Extraction Sockets –
A Correlative Histological,
Ultrastructural, and X-ray
Microanalytical Pilot Study

P. N. RAMACHANDRAN NAIR* AND HANS-ULRICH LUDER

Institute of Oral Biology
Section for Oral Structures and Development
Centre of Dental and Oral Medicine
University of Zurich, Zurich, Switzerland

FABRIZIO A. MASPERO
Department of Materials
Swiss Federal Institute of Technology (ETH)
Zurich, Switzerland

JÜRGEN H. FISCHER
Institute of Experimental Medicine
University of Köln, Köln, Germany

JENS SCHUG
Clinic for Preventive Dentistry, Periodontics and Cariology
Centre of Dental and Oral Medicine
University of Zurich, Zurich, Switzerland

ABSTRACT: This investigation studies porcine tissue response in tooth

extraction sockets treated with root replicas made out of -tricalcium phosphate
(-TCP; -Ca3(PO4)2) granules, molded and held together by thermal fusion of

*Author to whom correspondence should be addressed. E-mail: nair@zzmk.unizh.ch

JOURNAL OF BIOMATERIALS APPLICATIONS Volume 00 — 2006 1

0885-3282/06/00 0001–18 $10.00/0 DOI: 10.1177/0885328206054167
ß 2006 SAGE Publications

Copyright 2006 by SAGE Publications.

2 P. N. R. NAIR ET AL.

a thin film of polyglycolic–polylactic acid copolymer. Six left mandibular third

incisors (n ¼ 6) of experimental pigs are treated with the root replicas and four
contralateral incisors are used as nontreated controls (n ¼ 4). Two animals each
were killed at 20, 40, and 60 weeks of observation periods. The mandibular jaw
segments were prepared in toto for light microscopy by resin embedding and
serial ground sectioning. Additionally, one -TCP-treated socket at 60 weeks was
thoroughly investigated by correlative light, electron microscopic and electron
probe X-ray microanalysis to assess the bioabsorbability and host removal of the
replica material from the implant site. The extraction wounds of the animals
healed satisfactorily with very little histologically observable differences in the
healing pattern of the test and control sites. The -TCP was completely removed
from extracellular sites, but at 60 weeks, remnants of it were found in the
cytoplasm of multinucleated giant cells. The root replicas made out of -TCP
were biocompatible and bioabsorbable. Osseous healing occurred both in the test
and control sockets, but the healing process was delayed due to the presence of
-TCP particles.

KEY WORDS: alveolar process atrophy, alveolar ridge preservation,

biocompatibility, oral implants, oral wound healing, osseointegrated
dental prostheses, tooth extraction sockets.

INTRODUCTION

T he long-term prognostic, functional, and aesthetic success of the

conventional noninvasive and osseointegrated dental prostheses
depends on the presence of sufficient volume of healthy jaw bone [1].
The latter relates to proper postextraction healing and rehabilitation of
the alveolar process. The morphological events of human alveolar socket
healing after tooth extraction have been well documented [2]. It has long
been recognized that healing of tooth extraction sockets is associated
with a catabolic remodelling of the residual alveolar process that results
in loss of large volume of the jaw bone [3]. This atrophy of the alveolar
process has been described as a ‘. . . chronic progressive, irreversible and
disabling disease . . .’ [4] or reduction of residual ridges (RRR, [5]). The
etiology of the condition is unknown. Nevertheless, both systemic and
local factors have been suggested to be involved [5,6]. The rate of RRR is
rapid immediately after tooth extraction and the process is particularly
pronounced in the anterior maxilla.
Various preoperative and intraoperative measures have been
attempted to preserve the alveolar process. Careful oral hygiene and
precautions that minimize trauma during tooth extraction procedures
limit postoperative inflammation and associated bone loss. Other
measures include: (a) retention of the natural roots so as to preserve
the alveolar process, (b) insertion of prefabricated semianalogous
root form implants, and (c) application of various forms of guided bone
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 3

regeneration (GBR) techniques. Alloplastic bone substitutes [7–17] and

bone or osseous derivatives of isogenous [1,18–20], allogenous [7,11,
21,22], and xenogenous [23–25] origin have been used as osseoinductive
and/or osteoconductive materials in various GBR techniques. Numerous
attempts have been aimed at maintaining [7,9–15,18,23–29] or regener-
ating (or augmenting) [1,8,16,17,19–22, 30,31] the alveolar process.
Most of the publications were human case reports [7,10,14,16,18,20,
22,23,25,28,29,32] or animal studies [9,12,17,19,21, 26,30] with varying
and often conflicting outcomes assessed by clinical and radiographic
criteria. In several cases, there was histological examination of the
tissues removed during implant surgery [1,7,10,11,16–19,21,23–25,30].
Biodegradable osteosynthesis devices have been successfully used
for internal fixation of fractures in maxillofacial and orthopedic
surgeries [33,34]. The idea has been advanced [35] that custom-
made biodegradable root replicas applied as immediate implants in
extraction sockets could preserve the alveolar process. The animal
experimental application of polyglycolic acid (PGA) and subsequent
limited human therapeutic usage of polylactic acid (PLA) root replicas
have been reported to preserve the alveolar ridge [35,36]. Copolymers
of polyglycolic–polylactic acids (PLGA) eventually replaced the homo-
polymers for such clinical applications [15,37].
Clinical reports on bioabsorbable synthetic polymers, albeit limited,
have been positive, but investigations on PLGA showed an in vitro drop
of pH of a phosphate buffered (PBS) medium to well below 3 as a result
of degradation [38] of the copolymers into acidic monomers. In the body,
the latter are expected to be metabolized yielding energy, CO2, and
water via the citric acid cycle [15]. However, an in vivo lowering of pH
around the implanted root replicas can happen as a result of imbalance
in the release and elimination of the acidic degradation products with
possible adverse effects, such as demineralization of the residual bone
[37], inflammation, and even necrosis of tissues surrounding the replica.
Research [38] has shown that granules of -tricalcium phosphate
(-TCP, -Ca3(PO4)2) can be held together by thermal fusion of
a very thin film of PLGA coating of the granules. The resulting
agglomeration of -TCP granules can be shaped to any form by using
appropriate molds. On melting, the thin PLGA film would glue
the -TCP granules together exposing the surface of the latter,
but would not lower the pH of the surroundings on degradation.
The near spherical shape of the -TCP granules ensures an
interstitial porosity of the resultant product open to the exterior.
Therefore, the -TCP with low amounts of PLGA as a binding agent
has been suggested [38] to provide an almost neutral degradable
4 P. N. R. NAIR ET AL.

material to treat tooth extraction sockets for the prevention of

alveolar bone loss.
It is mandatory to study the reaction of mammalian tissues to
chemicals and foreign objects that are intended for various implant
therapies before such materials are clinically applied on a large scale in
human and animal patients. Therefore, the objectives of this investi-
gation were: (a) to study the histological response to treating tooth
extraction sockets with freshly prepared root replicas of -TCP in a
miniature swine model and (b) to answer the question as to whether or
not the -TCP is completely removed from the site of implantation.

MATERIALS AND METHODS

Animals and Teeth

A total of 10 teeth from six healthy adult miniature swines (Table 1)

were involved in this study. The pigs were kept under appropriate farm
conditions with food and water ad libitum. Two animals were randomly
allotted to each of the three observation groups, namely, 20, 40, and
60 weeks, respectively. Physical examination of the animals, photo-,
radiographic recordings and subsequent invasive oral surgical proce-
dures were done under general anesthesia at the scheduled times,
in accordance with German legislation on protection of animals,
veterinary professional standards and support. In addition to general
anesthesia, infiltration local anesthesia was used during tooth extrac-
tion to minimize bleeding and postoperative pain. In all six animals, the
extraction site of the left mandibular third incisor (tooth 33) was treated
with a root replica that was freshly prepared as described below. In four

Table 1. Summary of the animal data.

Observation Age Test Control

Animal (weeks) (years) Sex socket socket
SRP-1 20 6 M* 33 43
SRP-2 20 6 F 33 –
SRP-3 40 3 F 33 43
SRP-4 40 3 F 33 43
SRP-5 60 3 F 33 43
SRP-6 60 6 F 33 –

M* ¼ castrated male; F ¼ female.

Tooth 33 is mandibular left third incisor; tooth 43 is mandibular right third incisor.
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 5

of the six animals, the contralateral extraction site of tooth 43, was not
treated with the root replica as a split mouth control. The animals were
not used for any other experimental purpose. It is noteworthy that third
mandibular incisors are the smallest of porcine teeth that are amenable
to extraction without extensive trauma to the teeth and the surrounding
bones. Our own attempt to extract a second mandibular incisor in one
animal resulted in only a fractured crown of the tooth. Therefore, apart
from ethical considerations, the number of test and control sockets
could not be increased by making use of more extraction sockets in the
experimental animals involved.

Preparation of the Root Replicas

After extraction, the six test teeth were rinsed briefly in running cold
water and the soft tissue attached to the root surface was removed
mechanically. The replicas were prepared ‘chairside’ with -TCP
granules coated with a thin layer of PLGA (PLGA 50 : 50, Boehringer
Ingelheim, Ingelheim, Germany) as described in detail elsewhere [38].
Briefly, the granules (500–800 mm) were poured into the freshly
prepared root impression mold of the extracted tooth. The mold
containing the granules was then heated to a temperature of 80
C.
The PLGA surface film of the granules melt at 70
C so that the granules
glue together to form a root-shaped body on cooling. The replicas
revealed an interconnected porosity of about 50% (v/v) with an average
pore diameter of 200 mm. Preparation of the root replica molds took
about 5 min.

Clinical Procedures

After careful extraction of the teeth to avoid damaging the alveolar

processes of the animals, root replicas were inserted into the alveoli after
a few minutes. The edges of the gingival wounds were held together
by sutures that also retained the replicas in the alveoli. The sutures
were removed after 10 days of application. Empty contralateral alveolar
sockets, sutured after tooth extraction, served as controls. The animals
were clinically examined, photographed, and radiographed at various
intervals during the observation periods. After appropriate period of
observations, the animals were killed under general anesthesia at the
determined times (Table 1). Thereafter, the lower jaws were dissected
out, briefly rinsed in cold water and immersed in large volumes of half-
strength Karnovsky’s fixative [39]. The fixative solution was changed
6 P. N. R. NAIR ET AL.

after 24 h and the specimens were further fixed in cold storage (4
C) for
4–6 weeks.

Tissue Processing

The lower jaws of the six animals were divided along the midline
into left and right halves using a diamond disc (Vari/Cut, Leo
Corporation, St. Joseph, USA). Each half was then trimmed to
remove the mandibular portion distal to the canines. Using a band
saw (Exakt, Norderstedt, Germany) the mesial segments of the man-
dibles so prepared were further subdivided mesiodistally through the
midplane of the extraction sockets of teeth 33 and 43, respectively.
In the case of one animal of 60 weeks of observation period, a central
slice of about 0.8 mm thickness was removed from the test side
and saved for EponÕ (Fluka AG, Buchs, Switzerland) embedding.
The buccal and lingual segments of each mandibular specimen were
dehydrated in ascending grades of ethanol, thoroughly infiltrated with
and thereafter embedded in the commercial resin TechnovitÕ 7200
VLC (Kulzer, Wehrheim, Germany). The 0.8-mm thick central lower
jaw segment removed from the test side of the animal with 60 weeks
of observation period was substantially trimmed to reduce the speci-
men size to the area of the healing extraction socket of the tooth
33 that could be clearly orientated in a stereomicroscope. The non-
demineralized specimen was postfixed in 1.33% osmium tetroxide
(OsO4) buffered in 0.067 M s-collidine, dehydrated in ascending grades
of ethanol and embedded in EponÕ .

Scanning Electron Microscopy (SEM)

The cutting faces of the polymerized TechnovitÕ blocks were polished

with silicon carbide grinding paper followed by a polishing cloth
with diamond paste of 3, 1, and 0.25 grain size. The polished block
faces were then coated with a carbon layer of about 10–15 nm thick-
ness using a MED020/EVM030 electron beam evaporator (BAL-TEC,
Balzers, Lichtenstein) and examined in the backscatter mode in
a Stereoscan 180 scanning electron microscope (SEM, Cambridge,
Dortmund, Germany) equipped with a four-quadrant backscatter
detector setup to show atomic number contrast. Digital electron
micrographs were prepared at 15–20 kV of accelerating voltage and
a working distance of about 20 mm using a personal computer con-
nected to the SEM and the software WinDISS (Point Electronic, Halle,
Germany).
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 7

Ground Sections and Light Microscopy

Mesiodistal serial sections of about 50 mm thickness were prepared

using the microgrinding system [40] (Exakt, Norderstedt, Germany).
The sections were stained in toluidine blue and photomicrographed
using a photomicroscope M420 (Leica, Glattbrugg, Switzerland)
equipped with a CoolpixÕ 4500 (Nikon Corporation, Tokyo, Japan)
digital camera.

Transmission Electron Microscopy (TEM) and

Energy Dispersive Analysis of X-rays (EDAX)

From the EponÕ block, 1–1.5 mm thick survey sections were pre-
pared using a histodiamond knife (Diatome AG, Biel, Switzerland)
and the Reichert Ultracut E microtome (Leica, Glattbrugg,
Switzerland). The sections were stained in periodic acid-Schiff (PAS)
and methylene blue-Azur II and photomicrographed in bright and
polarized lights using a Dialux 20 photomicroscope (Leica, Glattbrugg,
Switzerland) equipped with the digital camera Progress C14
(Jenoptik, Eching, Germany) and an electronic imaging system
(ImageAccess, Imagic, Glattbrugg, Switzerland). After locating an
ideal site for ultrastructural evaluation and analysis, the selected area
in the epon block was target trimmed and thin sectioned with the
Reichert Ultracut E microtome (Leica, Glattbrugg, Switzerland).
Some of the thin sections were double contrasted with lead and
uranium salts [41,42] and examined in a Philips EM400T trans-
mission electron microscope (Philips, Endoven, The Netherlands).
Noncontrasted thin sections were used for EDAX with the aid of a
Philips CM120 scanning transmission electron microscope (STEM,
Philips, Endoven, The Netherlands).

RESULTS

Healing of the extraction wounds of the test and control sites in

all the animals was satisfactory by qualitative visual and radiographic
assessments at regular intervals. No signs of microbial infection,
exudation, or dehiscence of the wound could be observed at the
time of suture removal. Macroscopically, the gingival dimensions and
bony contours maintained the respective preoperative appearances as
could be judged by standardized photographic and radiographic
means.
8 P. N. R. NAIR ET AL.

General Histology

Treatment of the porcine tooth extraction sockets with -TCP

(Figure 1(A)–(C)) did not result in clear histomorphologically observ-
able advantages in the osseous healing pattern (Figure 1(A)–(C)) in
comparison to untreated contralateral control sites (Figure 1(D)–(F)).
At 20 weeks postoperatively, a distinct extraction socket was visible in
both the test (Figure 1(A)) and control (Figure 1(D)) specimens.
Spicules of bone could be observed to project into the extraction
sockets from the bottom and lateral walls of the alveoli. Horizontal
extension of the alveolar ridge seemed to narrow the cervical opening
of the extraction socket. At 40 weeks (Figure 1(B) and (E)) the sockets
were partially traversed by trabecular bone that formed a loose
osseous network. The latter became closer fitting at 60 weeks
(Figure 1(C) and (F)) of observation. A complete closure of the cervical
opening of the alveolar ridge could be observed in the test sites at
40 and 60 weeks (Figure 1(B) and (C)), compared to interruptions
noticeable in ridge healing of the contralateral controls (Figure 1(E)
and (F)).

SEM Visualization

Backscattered imaging in SEM at 20 weeks revealed distinct

extraction sockets at the test (Figure 2(A)) and control sites. The
former contained a substantial amount of electron-dense fine particles
distributed throughout the socket. At 60 weeks (Figure 2(B)), a distinct
trabecular network of bone could be observed around the socket area
that was much smaller than that in the 20-week specimens. The
60-week specimens (Figure 2(B) and (C)) contained similar electron-
dense particles as those observed at 20 weeks, but in much lesser
quantity. At a higher magnification (Figure 2(C)), the jaw bone
displayed in two distinct areas of electron densities. While most of the
bone was of high electron density, an osseous layer of varying thickness,
but of distinctly lesser electron density, lined the healing and remodeling
front of the socket wall.

Polarization Microscopy and TEM Visualization

The cellular and subcellular details of the test socket at 60 weeks were
analyzed using various microtechniques in EponÕ embedded semithin
(1.5 mm) and thin (80 nm) sections. The healing socket consisted of
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 9

Figure 1. Overview photomicrographs showing the histological status of healing porcine

extraction sockets (ES) of tooth 33 in animals at 20 (A), 40 (B), and 60 (C) weeks
postextraction that were implanted with biodegradable root replicas. Contralateral
extraction sockets of tooth (43), not treated with root replicas, provided the controls
(D–F). There were no histologically observable differences in the osseous healing of the
extraction sockets, except for the complete closure (B, C) of the alveolar ridge in the test
cases as against the interruptions noticeable in the ridge healing of contralateral controls
(arrows in E, F). 32, 42 ¼ left and right mandibular second incisors, respectively. Original
magnifications: (A)–(F), 4.8.
10 P. N. R. NAIR ET AL.

Figure 2. Low magnification backscattered scanning electron micrographs (A, B) of

the surfaces of two synthetic resin embedded specimens. Note the extraction sockets (ES)
of teeth 33 at 20 (A) and 60 (B) weeks of observation periods, respectively. Figure 2(A)
originates from that shown histologically in Figure 1(A). The rectangular demarcated area
in (B) is magnified in (C). Note the highly electron dense particles at 20 weeks post-
extraction (arrow in A). Much less material is still visible in the 60-week postextraction
specimen (arrows in B, C). The repairing osseous socket wall has a lower electron density
(arrowheads) than the rest of the bone. Original magnifications: BO ¼ bone. (A) 17.5,
(B) 15, (C) 62.

trabecular bone delimiting large pockets of well-vascularized soft

connective tissue that contained plenty of fat globules (Figure 3(A)).
Except for the presence of occasional lymphocytes, the area was free of
infiltrating inflammatory cells, such as polymorphonuclear leucocytes
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 11

Figure 3. Photomicrographs of a semithin section from the area of the extraction socket
of tooth 33 at 60 weeks postextraction, illustrated in Figure 2(B). The rectangular
demarcated area in (A) is magnified in (B). The trabecular bone (BO), blood vessels (BV),
fat globules (FG), and cellular elements are visible. A higher magnification of the
demarcated area in (B) (shown in C) reveals profiles of giant cells in bright field vision.
In polarized light, the same field shows numerous birefringent bodies (BB) in giant cells.
Original magnifications: (A) 11, (B) 100, (C, D) 520.

(PMN) and plasma cells. But a large number of multinucleated giant

cells, in isolated clusters, could be observed (Figure 3(B) and (C)). Their
nuclei were distributed randomly throughout the cytoplasm. The cyto-
plasm revealed inclusion bodies that appeared empty in bright field
(Figure 3(C)) but intensely birefringent in polarized light (Figure 3(D))
so that the area of the section appeared to be studded with brightly
illuminating particles against a dark background. Electron microscopi-
cally (Figure 4(A)), the inclusion bodies contained a highly electron-
dense material that remained intact within the inclusion bodies when
12 P. N. R. NAIR ET AL.

Figure 4. A transmission electron micrograph (A) showing profiles of giant cell cytoplasm
(GC) and nuclei (NU). Note the highly electron-dense material in numerous inclusion
bodies (IB) in the cytoplasm. X-ray microanalysis (B) of the electron-dense material
at the intersection of the two hairlines in the inset (arrow) revealed the presence of
predominantly calcium and phosphorus elements at the site. The same analysis done
at the intranuclear (C, arrow in the nucleus) and intact cytoplasmic control sites did not
reveal the presence of elemental calcium and phosphorus. Original magnification:
(A) 4400.
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 13

these were delimited by plasma membranes. However, when pushed

away from the original sites during sectioning, the electron-dense
material showed signs of disintegration. The birefringent electron-dense
bodies were observed only within the giant cells and not in the
interstitial extracellular areas.

X-ray Microanalysis

The giant cell inclusion bodies (Figure 4(B)), several cytoplasmic and
nuclear sites (Figure 4(C)) were subjected to element analysis using a
STEM/EDAX unit. The dye-resistant, birefringent, and electron-dense
inclusion bodies consistently revealed peaks of energy range of
elemental calcium (Ca) and phosphorus (P). Only one significant peak
of X-ray emission, in the range of carbon (C), could be registered from
the cytoplasmic and nuclear sites.

DISCUSSION

This study presents correlative histological, ultrastructural, and

X-ray microanalytical data on the biocompatibility and host removal of
-TCP-made root replicas applied as an immediate implant after tooth
extraction in a miniature swine model.
The idea [35] of applying biodegradable root replicas as immediate
implants in extraction sockets to preserve the alveolar process has not
been adequately tested by independent animal and human clinical
trials. Only two publications [35,36] describe the treatment of
extraction sockets with biodegradable root replicas. In an experimental
study in rabbits [35], it was found that insertion of custom-made root
replicas made out of PGA into the extraction sockets of second
maxillary incisors prevented palatal collapse of the implanted area.
Contralateral control sockets that did not receive any root replicas
showed clear collapse of the area. Subsequently, in a woman patient
[36], one extraction socket was treated with a chairside-made PLA root
replica. Only radiographic follow-up was possible and it was reported
that ridge height could be preserved during an observation period of
84 weeks. In a larger clinical trial [37] with eight human patients, solid
and porous forms of PLGA copolymers were used as root replicas before
insertion of definite metallic implants. In some of the cases, an initial
decline in the radiodensity of the alveolar processes surrounding the
extraction sockets could be observed, which suggested initial bone
demineralization.
14 P. N. R. NAIR ET AL.

The first aim of this study was to visualize potential tissue reaction
and healing pattern of porcine tooth extraction sockets treated with
-TCP root replicas at predetermined observation periods. Serial
ground sections of anterior mandibular regions of the experimental
pigs containing treated and contralateral nontreated sites at 20, 40,
and 60 weeks showed gradual bone healing of the extraction sockets. No
clearly observable advantages in the healing pattern of the extraction
sockets could be found between the test and control sites by the conven-
tional bright field microscopy. The absence of complications, such as
tissue necrosis or signs of inflammation indicates biocompatibility of
the root replicas. No quantitative assessment of the tissue components
of the healing alveolar sockets was done, since the small sample size is
unlikely to yield any more meaningful biological data of appropriate
statistical reliability.
The second objective was to investigate whether or not the -TCP
was completely removed from the site of implantation during a clinically
relevant period of observation. As cellular details and the fine particles
of -TCP could not be adequately resolved in 50-mm histological ground
sections, other suitable microanalytical methods were used to deter-
mine the degree of -TCP removal. Visualization of the treated and
nontreated control sockets in backscattered mode of SEM clearly
showed the presence of fine electron-dense particles in test sites, the
amount of which declined with increasing observation periods. Low
amounts of electron-dense material were still present in the specimens
of the longest observation period. However, backscatter images could
not clarify whether the particles were intra- or extracellular in nature.
The presence of clusters of multinucleated giant cells in the soft tissue
of the healing socket at 60 weeks indicated a foreign body host response.
The physical properties of the inclusion bodies, such as dye resistance,
birefringence, and high electron density are suggestive of the presence
of inorganic element(s). Electron probe microanalysis consistently
confirmed the presence of calcium (Ca) and phosphorus (P). The fact
that at 60 weeks, the Ca and P containing birefringent and electron-
dense particles were observed only within giant cells, suggests that most
of the -TCP of the root replica were biodegraded and/or bioabsorbed
by the host. Taken together, the evidence suggests that the Ca and P
observed in the inclusion bodies of the giant cells were remnants of
-TCP that were eliminated by the host cells. These intracellular
remnants of the -TCP may not be of clinical significance, because the
particles were within host cells that should be biologically eliminated in
due course, or would be removed during surgical re-entry for placement
of an osseointegrated implant.
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 15

CONCLUSIONS

The results of this study allow us to conclude that root replicas made
out of -TCP are biocompatible and bioabsorbable. Osseous healing
occurred in both the test and control sockets, but the healing process
appears to be delayed by the presence of -TCP particles.

ACKNOWLEDGMENTS

We are indebted to Dr K. Ruffieux, Department of Materials, Federal

Institute of Technology, Zurich, Switzerland, for the excellent coordina-
tion of this project and to Dr S. Jeschkeit and Dr C. Funke, Institute
of Experimental Medicine, University of Köln, Köln, Germany, for
their veterinary professional support. Our thanks are due to
Mr H.-P. Gautschi, Central Laboratory for Electron Microscopy,
University of Zurich, Zurich, Switzerland, for his help in electron
probe X-ray microanalysis; to Mrs J. Hofmann-Lobsiger and Mrs M.
Amstad-Jossi for the excellent technical assistance. We are indebted to
Dr David Figdor, Monash University, Clayton, Victoria, Australia for
the critical reading and editing of the manuscript.

REFERENCES

1. Buser, D., Dula, K., Hirt, H.P. and Schenk, R.K. (1996). Lateral Ridge
Augmentation using Autographs and Barrier Membranes: A Clinical Study
with 40 Partially Edentulous Patients, J. Oral Maxillofac. Surg., 54:
420–432.
2. Amler, M.H., Johnson, P.L. and Salman, I. (1960). Histological and
Histochemical Investigation of Human Alveolar Socket Healing in
Undisturbed Extraction Wounds, J. Am. Dent. Assoc., 61: 32–44.
3. Jahangiri, L., Delvin, H., Ting, K. and Nishimura, I. (1998). Current
Perspectives in Residual Ridge Remodeling and its Clinical Implications,
J. Prosthet. Dent., 80: 224–237.
4. Atwood, D.A. and Coy, W.A. (1971). Clinical Cephalometric and
Densitometric Study of Reduction of Residual Ridges, J. Prosthet. Dent.,
26: 280–295.
5. Atwood, D.A. (1962). Some Clinical Factors Related to Rate of Resorption of
Residual Ridges, J. Prosthet. Dent., 12: 441–450.
6. Mercier, P. (1988). Ridge Reconstruction with Hydroxylapatite Part 1.
Anatomy of the Residual Ridge, Oral Surg. Oral Med. Oral Pathol., 65:
505–510.
7. Becker, W., Clokie, C., Sennerby, L., Urist, M.R. and Becker, B.E. (1998).
Histological Findings after Implantation and Evaluation of Different
16 P. N. R. NAIR ET AL.

Grafting Materials and Titanium Micro Screws into Extraction Sockets:

Case Reports, J. Periodontol., 69: 414–421.
8. Block, M.S. and Kent, J.N. (1984). Long-term Radiographic Evaluation of
Hydroxylapatite-augmented Mandibular Alveolar Ridge, J. Oral Maxillofac.
Surg., 42: 793–796.
9. Cranin, A.N., Simons, A., Klein, M., Sirakian, A., Ashman, A. and Colmery,
B. (1995). The Use of Particulate, Microporous, Calcified Copolymer as a
Ridge Maintenance Device in Dogs, J. Vet. Dent., 12: 53–58.
10. Froum, S. and Orlowski, W. (2000). Ridge Preservation Utilizing an
Alloplast Prior to Implant Placement – Clinical and Histological Case
Reports, Pract. Periodont. Aesthet. Dent., 12: 393–402.
11. Froum, S., Cho, S.-C., Rosenberg, E., Rohrer, M. and Tarnow, D. (2002).
Histological Comparison of Healing Extraction Sockets Implanted with
Glass or Demineralized Freeze-dried Bone Allograft: A Pilot Study,
J. Periodontol., 73: 94–102.
12. Gauthier, Q. (1999). A New Injectable Calcium Phosphate Biomaterial for
Immediate Bone Filling of Extraction Sockets: A Preliminary Study in Dogs,
J. Periodontol., 70: 375–383.
13. Gross, J. (1995). Ridge Preservation using HTR Synthetic Bone Following
Tooth Extraction, Gen. Dent., 43: 364–367.
14. Lekovic, V., Camargo, P.M., Klokkevold, P.R., Weinlander, M.,
Kenney, E.B., Dimitrijevic, B. and Nedic, M. (1998). Preservation of
Alveolar Bone in Extraction Sockets using Bioabsorbable Membranes,
J. Periodontol., 69: 1044–1049.
15. Peltoniemi, H., Ashammakhi, N., Kontio, R., Waris, T., Salo, A.,
Lindqvist, C., Grätz, K. and Suuronen, R. (2002). The Use of
Bioabsorbable Osteofixation Devices in Craniomaxillofacial Surgery,
Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod., 94: 5–14.
16. Piattelli, A., Podda, G. and Scarano, A. (1997). Clinical and Histological
Results in Alveolar Ridge Enlargement using Coralline Calcium Carbonate,
Biomaterials, 18: 623–627.
17. Pinholt, E.M., Bang, G. and Haanaes, H.R. (1991). Alveolar Ridge
Augmentation in Rats by Bio-Oss, Scand. J. Dent. Res., 99:
154–161.
18. Becker, W., Urist, M., Becker, B.E., Jackson, W., Parry, D.A., Bartold, M.,
Vincenzzi, G., Georges, D.E. and Niederwanger, M. (1996). Clinical and
Histologic Observations of Sites Implanted with Intraoral Autologous
Bone Grafts or Allografts. 15 Human Case Reports, J. Periodontol., 67:
1025–1033.
19. Donos, N., Kostopoulos, L. and Karring, T. (2002). Alveolar Ridge
Augmentation using Resorbable Copolymer Membrane and Autogenous
Bone Grafts. An Experimental Study in Rat, Clin. Oral Impl. Res., 13:
203–213.
20. Raghoebar, G.M., Batenburg, R.H.K., Vissink, A. and Reintsema, H. (1996).
Augmentation of Localized Defects of the Anterior Maxillary Ridge with
Autogenous Bone before Insertion of Implants, J. Oral Maxillofac. Surg.,
54: 1180–1185.
 Biocompatibility of -Tricalcium Phosphate Root Replicas in Swine 17

21. Pinholt, E.M., Haanaes, H.R., Roervik, M., Donath, K. and Bamg, G. (1992).
Alveolar Ridge Augmentation by Osteoinductive Materials in Goats, Scand.
J. Dent. Res., 100: 361–365.
22. Nevins, M. and Mellonig, J.T. (1994). The Advantages of Localized Ridge
Augmentation prior to Implant Placement: A Staged Event, Int. J.
Periodontics Restorative Dent., 14: 97–111.
23. Artzi, Z. and Nemcovsky, E. (1998). The Application of Deproteinized
Bovine Bone Mineral for Ridge Preservation Prior to Implantation.
Clinical and Histological Observations in a Case Report, J. Periodontol.,
69: 1062–1067.
24. Artzi, Z., Tal, H. and Dayan, D. (2000). Porous Bovine Bone Mineral
in Healing of Human Extraction Sockets. Part 1: Histomorphometric
Evaluations at 9 months, J. Periodontol., 71: 1015–1023.
25. Carmagnola, D., Adiaens, P. and Berglundh, T. (2003). Healing Human
Extraction Sockets Filled with Bio-Oss, Clin. Oral Impl. Res., 14: 137–143.
26. Boyne, P.J. (1995). Use of HTR in Tooth Extraction Sockets to Maintain
Alveolar Ridge Height and Increase Concentration of Alveolar Bone Matrix,
Gen. Dent., 43: 470–474.
27. Iasella, J.M., Greenwell, H., Miller, R.L., Hill, M., Drisko, C., Bohra, A.A.
and Scheetz, J.P. (2003). Ridge Preservation with Freeze-dried Bone
Allograft and Collagen Membrane Compared to Extraction Alone for
Implant Site Development: A Clinical and Histologic Study in Humans,
J. Periodontol., 74: 990–999.
28. Lekovic, V., Kenney, E.B., Weinlaender, M., Han, T., Klokkevold, P.,
Nedic, M. and Orsini, M. (1997). A Bone Regenerative Approach to Alveolar
Ridge Maintenance Following Tooth Extraction. Report of 10 Cases,
J. Periodontol., 68: 563–570.
29. Nemcovsky, C.E. and Serfaty, V. (1996). Alveolar Ridge Preservation
Following Extraction of Maxillary Anterior Teeth. Report on 23
Consecutive Cases, J. Periodontol., 67: 390–395.
30. Barboza, E.P. (1999). Clinical and Histologic Evaluation of the
Demineralized Freeze-dried Bone Membrane used for Ridge
Augmentation, Int. J. Peridont. Restor. Dent., 19: 601–607.
31. Proussaefs, P.T., Valencia, G., Lozada, J. and Tatakis, D.N. (2002). A
Method to Assess the Clinical Outcome of Ridge Augmentation Procedures,
J. Periodontol., 73: 302–306.
32. Zubillaga, G., Von Hagen, S., Simon, B.I.D. and Deasy, M.J. (2003). Changes
in Alveolar Bone Height and Width Following Post-extraction Ridge
Augmentation using a Fixed Bioabsorbable Membrane and Demineralized
Freeze-dried Bone Osteoinductive Graft, J. Periodontol., 74: 965–975.
33. Bos, R.R.M., Boering, G., Rozema, F.R. and Leensland, J.W. (1987).
Resorbable Poly(l-lactide) Plates and Screws for the Fixation of Zygomatic
Fractures, J. Oral Maxillofac. Surg., 45: 751–753.
34. Partio, E.K., Merikanto, J., Heikkila, J.T., Ylinen, P., Mäkelä, E.A., Vainio,
J., Törmälä, P. and Rokkanen, P. (1992). Totally Absorbable Screws in the
Fixation of Subtalar Extra-articular Arthrodesis in Children with Spastic
Neuromuscular Disease, J. Ped. Orthop., 12: 646–650.
18 P. N. R. NAIR ET AL.

35. Suhonen, J., Suuronen, R., Hietanen, J., Marinello, C. and Törmälä, P.
(1995). Custom made Polyglycolic Acid (PGA) – Root Replicas Placed in
Extraction Sockets of Rabbits, Dtsch Z Mund Kiefer Gesichts Chir, 19:
253–257.
36. Suhonen, J.T. and Meyer, B.J.A. (1996). Polylactic Acid (PLA) Root Replica
in Ridge Maintenance after Loss of Vertically Fractured Incisor, Endod.
Dent. Traumatol., 12: 155–160.
37. Nair, P.N.R. and Schug, J. (2004). Observations on Healing of Human Tooth
Extraction Sockets Implanted with Bioabsorbable Polylactic-Polyglycolic
Acids (PLGA) Copolymer Root Replicas: A Clinical, Radiographic and
Histological Follow-up Report of Eight Cases, Oral Surg. Oral Med. Oral
Pathol. Oral Radiol. Endod., 97: 559–569.
38. Maspero, F.A. (2001). Biodegradable Open Porous Scaffolds for the
Prevention of Alveolar Bone Loss after Tooth Extraction: CO2-processing
and In vitro-behavior, Doctoral Thesis, Zurich, Switzerland, Swiss Federal
Institute of Technology (ETH).
39. Karnovsky, M.J. (1965). A Formaldehyde Glutaraldehyde Fixative of
High Osmolarity for use in Electron Microscopy, J. Cell Biol., 27:
137A–139A.
40. Donath, K. (1988). Die Trenn-Dünnschliff-Technik zur Herstellung
Histologischer Präparate von nicht scneidbaren Geweben und Materialien,
Der Präparator., 34: 197–206.
41. Fraska, J.M. and Parks, V.R. (1965). A Routine Technique for Double
Staining Ultrathin Sections using Uranyl and Lead Salts, J. Cell Biol., 25:
157–161.
42. Venable, J.H. and Coggeshall, R. (1965). A Simplified Lead Citrate Stain for
use in Electron Microscopy, J. Cell Biol., 25: 407–408.