PROF.

BIN SHI (Orcid ID : 0000-0002-3643-9475)

Accepted Article
Article type : Review

Outcomes of maxillary sinus floor augmentation without grafts in

atrophic maxilla: a systematic review and meta-analysis based on
randomized controlled trials

Running Title: Outcomes of sinus augmentation without grafts

List of authors: Yang Jing 1,2, *, Xia Ting2, *, Wang Hui3, Cheng Zhigang1, Shi Bin2

Dr. Yang Jing, DDS

Affiliation: 1. The Central Hospital of Wuhan, 26 Shengli street, Wuhan, 430014, People’s
Republic of China

2.The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST)
and Key Laboratory of Oral Biomedical Ministry of Education, School and Hospital of
Stomatology, Wuhan University, 237 Luoyu road, Wuhan, 430079, People’s Republic of
China

E-mail address: yangyangyj@sina.com

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/joor.12753

This article is protected by copyright. All rights reserved.

 Dr. Xia Ting, DDS

Affiliation: The State Key Laboratory Breeding Base of Basic Science of Stomatology
Accepted Article
(Hubei-MOST) and Key Laboratory of Oral Biomedical Ministry of Education, School and
Hospital of Stomatology, Wuhan University, 237 Luoyu road, Wuhan, 430079, People’s
Republic of China

E-mail address: tingzi90s@whu.edu.cn

Dr. Wang Hui，DDS

Affiliation: Hangzhou West Dental Hospital, 306 Tianmushan Road, Hangzhou,310006,

People’s Republic of China

E-mail address: 835832497@qq.com

Dr. Cheng Zhigang, DDS

Affiliation: The Central Hospital of Wuhan, 26 Shengli street, Wuhan, 430014, People’s
Republic of China

E-mail address: czgar068@126.com

Prof. Shi Bin, DDS, Professor (Corresponding author)

Affiliation: The State Key Laboratory Breeding Base of Basic Science of Stomatology
(Hubei-MOST) and Key Laboratory of Oral Biomedical Ministry of Education, School and
Hospital of Stomatology, Wuhan University, 237 Luoyu road, Wuhan, 430079, People’s
Republic of China. Tel.: +86 27 87686222; fax: +86 27 87683260

E-mail address: shibin_dentist@whu.edu.cn

This article is protected by copyright. All rights reserved.

 * Yang Jing and Xia Ting should be considered joint first author.
Accepted Article
Conflict of Interest Statement: no conflict of interest

Abstract

Background: Maxillary sinus floor augmentation without grafts has been more

widely used, but the efficacy is still controversial.

Purpose: The aim of this review was to systematically evaluate the effectiveness

of sinus floor augmentation without grafts in atrophic maxilla.

Methods: The electronic databases included PubMed, EMBASE and the

Cochrane Central Register of Controlled Trials. The meta-analysis was

conducted by Review Manager 5.1. The quality of evidence was assessed using

the Grades of Recommendation, Assessment, Development, and Evaluation

(GRADE).

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 Results：The electronic database and manual search yield 707 studies. After

critical selection, only 6 studies were eligible. Five studies with 336 implants
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were included in the meta-analysis compared sinus augmentation with grafts to

without grafts. No significant differences were found between the two groups in

implant survivals (P=0.94), marginal bone loss (P=0.73) and new bone density

(P=0.54). There was significantly more endo-sinus bone gain in the grafting

group (P=0.02). According to the GRADE, the levels of evidence were

moderate (implant survival and marginal bone loss), low (endo-sinus bone

gain), and very low (new bone density).

Conclusion: There were no significant differences between maxillary sinus

augmentation with and without grafts in short-term implant survivals.

Keywords: maxillary sinus floor augmentation; grafts; maxilla; implant

survivals; marginal bone loss; endo-sinus bone gain; new bone density

• Introduction

Osseointegrated implant placement is a highly predictable and widely used

treatment for the rehabilitation of partially or wholly edentulous patients. In

posterior maxilla, presence of maxillary sinus, frequent maxillary sinus

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 pneumatization, low bone density and rapid bone resorption following tooth

loss lead to big challenge in successful implant placement and excellent long-
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term result achievement.

Solutions for patients with atrophic maxilla include maxillary sinus lift, guided

bone regeneration, onlay or inter-positional grafts, the application of tilting or

short implants.1,2 Among those solutions, maxillary sinus lift is one of the most

widely used solutions for edentulous rehabilitation. In traditional sinus lift, no

matter lateral window approach or trans-alveolar procedure, different bone-

grafting materials are needed to maintain the space and induce bone

regeneration.3-5 Nowadays, with the development of the implant designs and

surgical techniques, studies have shown that sinus lift without grafts can also

induce bone formation in the maxillary sinus and result in favorable success

rate, which is considered less invasive, traumatic and costly.6-9 Recently several

randomized controlled trials and systematic reviews have compared the

effectiveness of two surgical options - sinus lift with and without grafts.10-12 But

whether to do the sinus lift without grafts alone is enough for the implant

success in the atrophic maxilla is still controversial. The aim of this systematic

review was to evaluate the efficacy of sinus lift without grafts in atrophic

maxilla. The null hypothesis was there were no significant differences between

graft group and without graft group in implant survivals, marginal bone loss,

new bone density, and endo-sinus bone gain.

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 Materials and methods
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Search for papers and selection

PubMed, EMBASE via OVID and the Cochrane Central Register of Controlled

Trials (CENTRAL) were searched for relevant studies published in English,

based on the PICO principle. The most recent electronic search was undertaken

on October 15, 2018. The design of the meta-analysis was registered on

international prospective register of systematic reviewers (PROSPERO), the

registration number was CRD42016009776.

A manual search was carried out in the following implant-related journals

including: British Journal of Oral and Maxillofacial Surgery, Clinical Implant

Dentistry and Related Research, Clinical Oral Implants Research, European

Journal of Oral Implantology, Implant Dentistry, Journal of Oral Implantology,

Journal of Oral and Maxillofacial Surgery, Journal of Dental Research, Journal

of Clinical Periodontology, Journal of Periodontology, International Journal of

Prosthodontics, International Journal of Oral and Maxillofacial Surgery,

International Journal of Oral and Maxillofacial Implants, and the International

Journal of Periodontics and Restorative dentistry.

Inclusion criteria were: 1) Any studies with data on outcomes of sinus lift

without grafts in atrophic maxilla. 2) Only randomized controlled trials

involving a minimum follow-up of 6 months. 3) Studies had to have a minimum

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 sample size of 5 patients and therefore a minimum of 10 implants in each group.

4) Publications in the dental literature in English.

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Two independent reviewers identified potential studies according to the

inclusion criteria through title and abstract screening, then made the final

decision after full-text reading. Any disagreement was resolved by consensus.

Referred to the successive reports on the same patients, the most recent

publication was included. In addition, references of relevant studies were also

hand-searched and assessed according to the method mentioned above.

Assessment of quality of papers included

According to the Cochrane Handbook for Systematic Reviews of Interventions

5.1.0, the quality assessment procedure was done by two independent review

authors. The included study mainly assessed: random sequence generation,

allocation concealment, blinding of participants and personnel, blinding of

outcome assessment, incomplete outcome data, selective reporting and risk of

other bias.

Statistical analysis

The significant discrepancies in the estimates of the treatment effects from

different trials were to be assessed by means of Cochrane’s test for

heterogeneity. When P＜0.1 or I2≥50%, the results would be considered as

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 substantial heterogeneity. When appropriate, meta-analysis was applied by

using the Review Manager (RevMan) 5.1. Risk ratios were applied to
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discontinuous variable and mean difference were applied to continuous variable.

When there was substantial heterogeneity that could not readily be explained,

random effects meta-analysis might be used to incorporate heterogeneity among

trials, otherwise the fixed effect meta-analysis was used to discount

heterogeneity.

Overall quality assessment of the evidence across outcomes

Overall quality assessment of the evidence was performed by using the GRADE

profiler 3.6. The GRADE system classifies the quality of evidence into four

grades: 1) High: further research is very unlikely to change our confidence in

the estimate of effect. 2) Moderate: further research is likely to have an

important impact on our confidence in the estimate of effect and may change

the estimate. 3) Low: further research is very likely to have an important impact

on our confidence in the estimate of effect and is likely to change the estimate.

4) Very low: any estimate of effect is very uncertain.

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 • Results
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3.1 Results of the search and characteristics of the studies included

A total of 707 studies were retrieved by the electronic and hand searches, of

which 17 papers10-26 were remained for full-text reviewing, and the flow

diagram of the selection procedure was present in Fig 1. Seven trials10-16

compared sinus lift with and without grafts, included 3 trials12,14-15 which were

successive reports on the same patients. One trial17 compared osteotome sinus

lift without grafts to short implants. Finally, 5 articles10,11,13,14,16 were included in

this systematic review and meta-analysis. The basic characteristics of the

included studies were detailed in table 1.

3.2 Quality assessment of included articles

The risk of bias assessment was summarized in Fig 2. According to the

Cochrane Handbook, three studies11,14,16 were assessed as at low risk of bias. In

random sequence generation, allocation concealment, and blinding of outcome

assessment the judgment of “unclear risk of bias” was given in one trial 10. In

blinding of participants and personnel, two trials10,13 presented the “unclear risk

of bias”.

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 3.3 Data synthesis and results of meta-analysis
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Five trials10,11,13,14,16 were included in the meat-analysis compared sinus lift with

and without grafts.

All the included studies reported on the survival rate of the implants. The test

for heterogeneity showed no evidence of heterogeneity (P=0.96, I2=0%), so the

meta-analysis was applied by fixed-effects model. Comparison of implant

survival between graft and without graft is illustrated as a forest plot (Fig 3).

There was no statistically significant difference between the two groups, with a

RR (risk ratio) of 1.00 (95% confidence interval (CI) 0.96 to 1.04, P=0.94).

Three of the included trials reported on the endo-sinus bone gain.11,13,14 The test

for heterogeneity showed no significant heterogeneity (P=0.40, I2=0%). So, the

meta-analysis was applied by using fixed-effects model (Fig 4). Meta-analysis

revealed statistically more endo-sinus bone gain in the graft group than in the

group without graft (95% CI -1.28 to -0.11, P=0.02).

Two studies reported on the changes of peri-implant marginal bone level.11,14

The test for heterogeneity showed no significant heterogeneity (P=0.72,

I2=0%). The meta-analysis was applied by using the fixed-effects model (Fig

5). There was no statistically significant difference between the two groups

(95% CI -0.18 to 0.26, P=0.73).

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 Two studies assessed outcomes of the endo-sinus new bone density.10,13 The test

for heterogeneity showed significant heterogeneity between the two trials

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(P=0.09, I2=65%). The meta-analysis was applied by using the random-effects

model (Fig 6). There was no statistically significant difference between the two

groups (95% CI -160.32 to 306.63, P=0.54).

3.4 Quality of evidence

Table 2 shows the GRADE summary of findings for the levels of the four main

outcomes (survival rate of the implants, endo-sinus bone gain, peri-implant

marginal bone level, new bone density). Reasons for upgrade and downgrade

are also shown in details.

• Discussion

This meta-analysis showed there were no significant differences between

the groups of implants placed with or without grafting in implant success rate,

the changes of peri-implant marginal bone level and the density of newly

formed bone around implants. However, in sinus lift, the bone grafts group

showed more endo-sinus bone gain than no grafts group. According to GRADE

，the quality of the evidence about implant success rate and the changes of

peri-implant marginal bone level was moderate. The quality of evidence about

endo-sinus bone gain was low. And the quality of the evidence about the density

of newly formed bone around implants was very low.

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 Recently, two systematic reviews about the use of bone grafts in sinus lift

have been published. Moraschini et al. found there was no significant difference
Accepted Article
in the implant success rate and endo-sinus bone gain by comparing using and

not using bone grafts material.27 The study included 18 articles, of which only 4

articles in RCT. Their meta-analysis included 6 studies, repeated studies (two

sequential studies for the same patient12,15) and non-randomized control trials

were not eliminated, and the quality grade of the evidence was not evaluated.

Nasr et al.28 included 6 papers, two of which were serial reports of the same

research objects. But in the meta-analysis, the authors did not eliminate repeated

reports from the same research objects. Furthermore, the grade evaluation of

evidence is different from the present article because it concerned the overall

evaluation of the study, but not for each outcome index. In addition, Nasr

included Esposito et al. and Felice et al’ s research, which compared using bone

grafts materials and using rigid inion membrane in sinus lift. 29,30

Among the four-outcome index, the success rate of implant was the ultimate

indicator of evaluation. The selected literatures described the failure implant in

detail, two of them reported a success rate of 100%. One failure was observed in

the patient who presented sinusitis13. Three implants were lost because of peri-

implantitis 11,15. Two early failures were related to the placement of implants in

fused corticals (mono-cortical bone), where the implant primary stability was

difficult to achieve12. None of the failed implants was directly caused by the

presence or not of the graft. This meta-analysis showed that between graft and

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 no graft group in sinus lift there were no significant differences in implant

success rate. But at the same time, two points must be pointed out. First, this
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conclusion is based on the data of only five clinical trials10,11,13,14,16, the follow-

up time of two trials10,13 lasted for only 6 months, only one14 follow-up period of

the five trials lasted for 5 years (the overall sample size in this study was 37

implants); Second, as for the short-term (less than 1year) success rate of the

implant the quality of the evidence has not reached a high level. Therefore, we

should be cautious in making clinical decisions. Even though it is not necessary

to graft in order to get better implant survival rate, that doesn’t mean graft has

no benefit for sinus lift. The bone graft material can better support the sinus

floor mucosa and maintain the stability of the osteogenesis space. Especially

when the diameter of the apical segment of the implant is small, the use of the

bone graft material can disperse the pressure of the sinus membrane, and

prevent osteogenic space reduction caused by mucosal collapse.

The outcome indicator of the changes of peri-implant marginal bone level

might be considered as a predictor of long-term clinical outcome of implants.

The results of the meta-analysis showed that there was no statistical difference

between the graft group and no graft group. This result was consistent with the

result of success rate of implant. Therefore, there may be

no significant difference in the long-term (≥5 years) success rate between the

two surgical types.

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 Another important outcome was the comparison of the amount of the new

bone formation in maxillary sinus. Some authors reported that the amount of
Accepted Article
newly formed bone depends on maxillary residual bone height. Nedir et al. was

the first to report a strong correlation between higher endo-sinus bone gain and

reduced residual bone height31. And according to the comparative radiographic

study over two years by Kim et al, the mean gain in alveolar height was

inversely related to the residual bone height32. However, Si et al. claimed the

opposite that the endo-sinus new bone formation was not significantly

correlated with the residual bone height in their 3-year randomized controlled

clinical trial22. Yang et al. reported also no significant correlation between the

new bone formation and the residual bone height33. The residual bone height is

critical in obtaining initial stability and selecting which program to operate, but

may not directly influenced the amount of new bone formation. Furthermore,

some authors believe that maxillary sinus elevation without grafting can provide

only a small or moderate amount of new bone formation, the sinus-lift

technique should be used without grafting only when a small amount of new

bone formation is necessary around implants placed in the maxillary sinus

cavity 34,35. However, other study has shown that maxillary sinus elevation

without grafting in extreme conditions (residual bone height ≦4mm) also

provides sufficient new bone formation to maintain implant stability 14.

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 This meta-analysis showed that in sinus lift, the grafting group had more

new bone formation than the no grafting group. This result was in line with
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previous studies12,14,34. However, it might be premature to draw a conclusion

that the amount of the new bone formation in the bone grafting group is greater

than that in the non-bone grafting group. First, according to the GRADE rating,

the quality of the evidence is low. Secondly, the results were based on only

three clinical studies11,13,14, the follow up period of which were six months, three

years, and five years. In the medium-term (1 to 5years) clinical study，the

researchers stated that the amount of new bone formation reduced from

5.66±0.99mm at 6 months to 3.17±1.95 mm at 36 months in bone grafting

group11. In the long-term (≥5years) clinical study, Nedir et al. have reported a

slight decrease in dome height above the implant apex, the mean ESBG

decreased from 5.0±1.3mm at 1 years to 4.8±2mm at 5 years in bone grafting

group 14. However, in the no grafting group was a growth process. Si et al.

reported the endo-sinus bone gain increased from 2.06±1.01mm at 6 months to

3.07±1.68mm at 36 months11. Nedir et al. have shown that peri-implant bone

was mainly gained during the first year, with no significant change thereafter 14.

Because of the amount of the new bone formation in the maxillary sinus derives

from the radiological imaging data, it was impossible to conclude that the bone

in the grafting group was completely transformed into autogenous bone. Since

the anorganic bovine bone material appears to undergo slow or even no

resorption for up to 10 years36,37. It was speculated that this inconformity was

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 due to the absorption and transformation of autogenous bone but not the

anorganic bovine bone. As a result, subsequent long-term clinical trials might

Accepted Article
be more reliable. The final factor needs to be considered was that some studies

have suggested that the amount of new bone formation and the length of the

implant protruding into the maxillary sinus in the process of the lift were

positively correlated.11,18 But it doesn't mean to pursue too much length of the

implant protruding into the sinus. An animal study by Sul et al38 showed that

there was no difference between the 4mm protruding implant and 8mm

protruding implant regarding new bone height in the sinus. The excessive IPL

(8mm protruding into the sinus) might lead to excessive tension of the maxillary

sinus mucosa. The integrity of the mucosa might be destroyed, with no bone

tissue around the apical segment of the implant, and even debris accumulated on

the exposed surfaces of the implants. Therefore, comparing the amount of new

bone formation in groups of implants placed with and without grafting, the

length of the implant protrusion into the sinus should be taken into account

during the experimental design process. Unfortunately, this factor in the studies

included in the present review was not considered.

The last outcome indicator was the bone mineral density of the new bone

in the maxillary sinus. The conclusion was that there was no significant

difference in the peri-implant bone density between the grafting group and no

grafting group. The level of evidence was very low. The results were very

uncertain because the study included a small sample size --- only two studies

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 with a follow-up period of only 6 months.10,13 More clinical data was needed to

support this conclusion.

Accepted Article
The GRADE system was used to evaluate the level of evidence. The

reason for this quality grade result was that limited evidence comes from 5

randomized controlled trials. And other reasons: 1. moderate risk of bias in two

studies10,13; 2. the study controlled the main factors (sinus lift with and without

grafts), but not the other factors such as operation mode in sinus lift (lateral

window approach or trans-alveolar procedure), follow-up time, bone grafts

materials, the length of the implant protruding into the maxillary sinus in the

process of the lift etc.

The advantages of this evaluation system were: extensive and relatively

comprehensive information retrieval, good systematic evaluation design,

appropriate quality evaluation, and heterogeneity were explored.

Limitations of the study included: 1. Potential heterogeneity among

studies. The heterogeneity here might come from the obvious distinction

between these studies：the operation mode in sinus lift, follow up time, types of

bone grafts materials in sinus lift, the length of the implant protruding into the

maxillary sinus in the process of the lift, implant length and diameter, etc. 2.

potential selective bias, the number of studies and overall sample size of the

meta-analysis were relatively small.

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 5.Conclusion
Accepted Article
The review showed that there is no significant difference between sinus lift with

and without grafts in the short-term success rate, the changes of peri-implant

marginal bone level and the density of newly formed bone around implants. But

the grafting group had more new bone formation than the no grafting group in

the short-term follow-up. An experienced clinician may consider not to use

bone grafts during sinus lift. However, these findings are based on a few

randomized studies including a low number of subjects, with short follow-up

periods. More studies with a strict design should be conducted incorporating a

larger pool of patients and longer follow-up (at least more than 5 years).

there were no significant differences between the groups of implants placed

with or without grafting in implant success rate, the changes of peri-implant

marginal bone level and the density of newly formed bone around implants.

However, in sinus lift, the bone grafts group showed more endo-sinus bone gain

than no grafts group.

Acknowledgment

The authors declare no conflicts of interest associated with this study and

there has been no significant financial support for this work. We further confirm

that there was no ethical approval required in this article.

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Accepted Article
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Accepted Article
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ccepted Articl Table 1 The basic characteristics of included studies
References No.of study design Age(years) Surgical RBH implant survivals MBL (mm) new bone density endo-sinus bone gain(mm) Follow-
patients/implants MD（） technique （mm） up time
【10】
Altintas NY 2013 14/24 prospective randomized 49.5（23-80） lateral wall 4-6 100% N/A 254.91±246.429（no grafting） N/A 6m
controlled approach 16.25±438.704（grafting）
Borges FL 2011
【13】
15/54 prospective randomized 57.9 lateral wall ≥3 96.4% (no grafting) N/A 194.42±84.75（no grafting） 7.9±3.6（no grafting） 6m
controlled approach 100% (grafting) 207±143.58（grafting） 8.3±2.6（grafting）

Marković A 2016
【16】
45/180 prospective randomized 56.7 OSFE 6.59± 0.45 100% (success) N/A N/A N/A 29.7m
【 】
Nedir R2017 14 12/37 prospective randomized 57.6±4.7 OSFE 2.4± 0.9 94.1% (no grafting) 0.6±0.9（no grafting） N/A 3.8±1（no grafting） 60m
90.00% (grafting) 0.7±1.4（grafting） 4.8±1.2（grafting）
【11】
Si MS 2013 41/41 double-blind 48.5（19-78） OSFE 4.63±1.31 95.0% (no grafting) 1.38±0.23（no grafting） N/A 3.07±1.68（no grafting） 36m
randomized 95.2% (grafting) 1.33±0.46（grafting） 3.17±1.95（grafting）
Label: “OSFE”: osteotome sinus floor elevation; " N/A “: not available; “m": month.

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 Table 2. Summary of finding: overall quality assessment of the evidence

across outcomes
Accepted Article
sinus floor elevation without grafting versus grafting for atrophic sinuses

Patient or population: patients with atrophic sinuses

Intervention: sinus floor elevation without grafting versus grafting

Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk

Control Sinus floor elevation without grafting

versus grafting

implant success Study population RR 1.00 336 ⊕⊕⊕⊝

(0.99 to 1.04) (5 studies) moderate1
986 per 1000 986 per 1000
(976 to 1000)

Moderate

976 per 1000 976 per 1000

(966 to 1000)

new bone gain The mean new bone gain in the 126 ⊕⊕⊝⊝
intervention groups was 0.69 lower (3 studies) low2,3
(1.28 to 0.11 lower)

crestal bone loss The mean crestal bone loss in the 74 ⊕⊕⊕⊝
intervention groups was 0.08 higher (2 studies) moderate4
(0.13 lower to 0.28 higher)

average bone density The mean average bone density in the 77 ⊕⊝⊝⊝
intervention groups was 73.16 higher (2 studies) very low5,6,7
(160.32 lower to 306.63 higher)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95%
confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1
Altintas NY 2013, Borges FL 2011 showed unclear risk of bias, which indicated serious limitations; this will downgrade the quality of evidence for this
outcome by 1 level.
2
Borges FL 2011showed unclear risk of bias, which indicated serious limitations; this will downgrade the quality of evidence for this outcome by 1 level.
3
total (cumulative) sample size is less than 400, downgrades 1 level.
4
total (cumulative) sample size is less than 400, downgrades 1 level.
5
Altintas NY 2013, Borges FL 2011 showed unclear risk of bias, which indicated serious limitations; this will downgrade the quality of evidence for this
outcome by 1 level.
6
(P=0.09, I2=65%), downgrades 1 level.
7
total (cumulative) sample size is less than 400, downgrades 1 level.

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 Figure legends
Accepted Article
Figure 1．PRISMA flow diagram of the selection procedure.

Figure 2. Risk of bias summary: review authors' judgements about each risk of

bias item for each included study.

Figure 3. Forest plot comparing implant survival between graft and without

graft groups.

Figure 4. Forest plot comparing endo-sinus bone gain between graft and without

graft groups.

Figure 5. Forest plot comparing peri-implant marginal bone level between graft

and without graft groups.

Figure 6. Forest plot comparing endo-sinus new bone density between graft and

without graft groups.

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Accepted Article

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Accepted Article

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Accepted Article

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