Frequent and Persistent Salivary Gland Ectasia and Oral Disease After COVID-19.

The clinical picture of coronavirus disease 2019 (COVID-19) in various target organs has been extensively studied and described. However, relatively little is known about the characteristics of oral cavity involvement. This is surprising, considering that oral mucosal and salivary gland cells are known targets for the direct replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and that the presence of the virus in saliva is a source of transmission of the infection. The aim of our study was to investigate the presence and prevalence of oral manifestations in COVID-19 survivors. We profiled the oral involvement in 122 COVID-19 survivors that were hospitalized and followed up at a single-referral university hospital in Milan, Italy, between July 23, 2020 and September 7, 2020, after a median (interquartile range) time from hospital discharge of 104 (95 to 132) d. We found that oral manifestations, specifically salivary gland ectasia, were unexpectedly common, with oral manifestations being detected in 83.9% while salivary gland ectasia in 43% of COVID-19 survivors. Salivary gland ectasia reflected the hyperinflammatory response to SARS-CoV-2, as demonstrated by the significant relationship with C-reactive protein (CRP) and lactate dehydrogenase (LDH) levels at hospital admission, and with the use of antibiotics during acute disease. Both LDH levels and antibiotic administration survived as independent predictors of salivary gland ectasia at multivariable analysis. Temporomandibular joint abnormalities, facial pain, and masticatory muscle weakness were also common. Overall, this retrospective and prospective cohort study of COVID-19 survivors revealed that residual damage of the oral cavity persists in the vast majority of patients far beyond clinical recovery, and suggests that the oral cavity represents a preferential target for SARS-CoV-2 infection. Further studies are needed to clarify the connection between SARS-CoV-2 infection and oral disorders.

Accuracy of Edentulous Computer-Aided Implant Surgery as Compared to Virtual Planning: A Retrospective Multicenter Study.

PURPOSE: To evaluate the accuracy of computer-aided dental implant positions obtained with mucosal-supported templates as compared to Three-Dimensional (3D) planning. MATERIALS AND METHODS: One-hundred implants were inserted into 14 edentulous patients using the All-on-4/6 protocol after surgical virtual planning with RealGUIDE, 3DIEMME, and Geomagic software. After 6 months, three-dimensional neck (V) and apex (S) spatial coordinates of implants and angle inclination displacements as compared to virtual plans were evaluated. RESULTS: The S maxilla coordinates revealed a significant discrepancy between clinical and virtual implant positions (p-value = 0.091). The V coordinates showed no significant differences (p-value = 0.71). The S (p-value = 0.017) and V (p-value = 0.038) mandible coordinates showed significant discrepancies between the clinical and virtual positions of the screws. Implant evaluation showed a 1-mm of the horizontal deviation in the V point and a 1.6-mm deviation in the S point. A mean 5° angular global deviation was detected. The multivariate permutation test of the S (p-value = 0.02) confirmed the difference. Greater errors in the mandible were detected as compared to the maxilla, and a higher S discrepancy was found in the posterior jaw compared to the anterior section of both the mandible and maxilla. CONCLUSIONS: Computer-aided surgery with mucosal-supported templates is a predictable procedure for implant placement. Data showed a discrepancy between the actual dental implant position as compared to the virtual plan, but this was not statistically significant. However, the horizontal and angle deviations detected indicated that flap surgery should be used to prevent implant positioning errors due to poor sensitivity and accuracy in cases of severe jaw atrophy.

The association between minor recurrent aphthous stomatitis (RAS), children's poor oral condition, and underlying negative psychosocial habits and attitudes towards oral hygiene.

BACKGROUND: Minor Recurrent Aphthous Stomatitis (RAS) represents a disease which is very difficult to prevent. This case-control study focused on possible associations between minor Recurrent Aphthous Stomatitis in children, their oral health, and underlying behavioral indexes of children's attitudes and habits pertaining to (home) oral hygiene, with the further goal of enabling the dentist to prevent these specific kind of lesions, both from a clinical and a broader psychosocial perspective. METHODS: Four hundred one school-children (5-10 years old) in Milan (Italy) were submitted to an intra-oral examination, and interviewed with the aid of a brief psychosocial questionnaire. RESULTS: At the clinical level, statistically significant associations were observed between the presence of decayed teeth and minor Recurrent Aphthous Stomatitis (Odds Ratio: 3.15; 95% CI: lower limit 1.06; upper limit: 9.36; Z-test: 2.07, p = 0.039; Chi-square = 4.71, p = 0.030), and between the Decayed Missing or Filled Teeth (DMFT) index and minor aphthous stomatitis (Odds Ratio: 3.30; 95% CI: lower limit 1.13; upper limit: 9.67; Z-test = 2.18, p = 0.029; Chi-square = 5.27; p = 0.022), both results pointing to a significant increase-by circa 3 times-in the risk of developing minor Recurrent Aphthous Stomatitis in children exposed to the two above-identified factors (i.e., the presence of decayed teeth and a clearly compromised oral condition, as signaled by the DMFT index), if compared with the risk run by their non-exposed counterparts. At the psychosocial level of analysis, statistically significant associations were observed (1) between children's practice of spontaneously brushing teeth when not at home and a comparatively lower (i.e. better) Decayed Missing or Filled Teeth index (Chi-square: 8.95; p = 0.011), and (2) between receiving parental aid (e.g., proper brushing instructions) while practicing home oral hygiene and a significantly reduced presence of decayed teeth (Chi-square = 5.40; p = .067; Spearman's Rho, p = .038). Further, significant associations were also observed between children's reported severity of dental pain and both (a) the presence of decayed teeth (Chi-square = 10.80; p = 0.011), and (b) children's (poor) oral health condition as expressed by the Decayed Missing or Filled Teeth index (Chi-square = 6.29; p = 0.043). Interestingly, specific lifestyles and social status, showed no systematic association to other clinical or psychological/psychosocial indices. CONCLUSIONS: These systematic relations suggest that, in the presence of Recurrent Aphthous Stomatitis in pediatric patients, the dentist should carefully monitor children for potential carious lesions, implement protocols of prevention to control Recurrent Aphthous Stomatitis disease in children affected by caries, and also be particularly aware of the right or wrong habits children may acquire in the course of continued social exchange with their caregivers and peers.

Etiological periodontal treatment with and without low-level laser therapy on IL-1ß level in gingival crevicular fluid: an in vivo multicentric pilot study.

Cytokine proteins may have important roles during different human physiological and pathological processes. In the oral cavity, the bone loss and periodontal tissue pathology was related to inflammatory process activation. The aim of the present study was to assess the effects of etiological periodontal therapy with and without the use of Low Level Laser Therapy (LLLT) on clinical periodontal parameters and interleukin (IL)-1ß level in gingival crevicular fluid (GCF) from chronic periodontitis (CP) patients. Thirty non-smoker CP patients were selected from the Foggia University Dental Clinic and other 2 private dental clinics. All patients were divided into two homogeneous randomized groups: 15 patients were treated with only scaling and root planing (group 1) and 15 patients with scaling and root planing etiological treatment and LLLT (group 2). In all sites, at baseline before treatment, the periodontal pocket depth (PPD) and bleeding on probing (BOP) were measured. In the PPD sites, the GCF samples were collected from 30 deep (≥5 mm) and shallow (≤3 mm) sites and IL-1ß were evaluated at baseline, after 10 days and 1 month. In all the samples at baseline, the IL-1ß concentration in GCF and BOP rate were significantly higher at deep PPD sites than at the shallow ones. After 10 days in all samples no PPD improvement was observed in the BOP rate but the IL-1 ß level was statistically significantly improved (p<0.005) in group 2 compared to group 1. At 10 days and 1 month, in all deep PPD sites, PPD and BOP improvements were observed. At same time, IL-1ß levels were lower and statistically significantly (p<0.005) improved in group 2 compared to group 1. The results confirmed that the periodontal etiology treatment of deep PPD sites with or with-out associated LLLT promotes periodontal health. Etiological treatment associated with LLLT, improves BOP and inflammation in periodontal disease. Moreover, the IL-1ß concentration changes in GCF suggest these cytokines as a predictable marker of gingival inflammation in chronic periodontitis patients.

Prosthetic management of patients with oro-maxillo-facial defects: a long-term follow-up retrospective study.

INTRODUCTION: The aim of this study is to determine the outcome of maxillofacial prosthetic rehabilitation after oncological resections, including both intra- and extra-oral prosthetic devices. METHODS: In this study were included 72 patients, who have undergone an intra or extra-oral maxillofacial prosthetic rehabilitation after an oncologic resection. Tumors on the head and neck were analyzed and the defects of these resections have been divided in two different groups: intra and extra-oral defects. RESULTS: 72 participants were treated with maxillofacial prosthesis, 3 of which with post-traumatic wounds and 69 with resections of tumors on the head and neck. Of the 69 treated for neoplastic disease, 43 received an intraoral prosthesis (palatal obturator) and 29 with an extraoral epithesis (18 with nasal prostheses, 8 with orbital implants and 3 with ear implants). The group included patients with different types of tumors. All the patients were evaluated in terms of aesthetic appearance after the construction of the prostheses and the results were satisfactory. CONCLUSION: Within the limitations of this study, after the use of maxillofacial protheses patients feel more confident and self-assured. Maxillofacial protheses are a good solution in order to improve the life's quality in patients with tumors resections: prostheses are easy to handle and provide a satisfying social interaction for the patients.

A New Total Digital Smile Planning Technique (3D-DSP) to Fabricate CAD-CAM Mockups for Esthetic Crowns and Veneers.

Purpose. Recently, the request of patients is changed in terms of not only esthetic but also previsualization therapy planning. The aim of this study is to evaluate a new 3D-CAD-CAM digital planning technique that uses a total digital smile process. Materials and Methods. Study participants included 28 adult dental patients, aged 19 to 53 years, with no oral, periodontal, or systemic diseases. For each patient, 3 intra- and extraoral pictures and intraoral digital impressions were taken. The digital images improved from the 2D Digital Smile System software and the scanner stereolithographic (STL) file was matched into the 3D-Digital Smile System to obtain a virtual previsualization of teeth and smile design. Then, the mockups were milled using a CAM system. Minimally invasive preparation was carried out on the enamel surface with the mockups as position guides. Results. The patients found both the digital smile design previsualization (64.3%) and the milling mockup test (85.7%) very effective. Conclusions. The new total 3D digital planning technique is a predictably and minimally invasive technique, allows easy diagnosis, and improves the communication with the patient and helps to reduce the working time and the errors usually associated with the classical prosthodontic manual step.

Vascular endothelial growth factor and nitric oxide synthase expression in human tooth germ development.

Vascular Endothelia Growth Factor (VEGF) and Nitric Oxide Synthase (NOS) expression, were evaluated in human tooth germs at two different stages of embryogenesis, to clarify the role of angiogenesis during tooth tissue differentiation and growth. Seventy-two third molar germ specimens were selected during oral surgery. Thirty-six were in the early stage and 36 in the later stage of tooth development. The samples were evaluated with Semi-quantitative Reverse Transcription-Polymerase chain Reaction analyses (RT-PcR), Western blot analysis (WB) and immunohistochemical analysis. Western blot and immunohistochemical analysis showed a VEGF and NOS 1-2-3 positive reaction in all samples analysed. VEGF high positive decrease reaction was observed in stellate reticulum cells, ameloblast and odontoblast clusters in early stage compared to later stage of tooth germ development. Comparable VEGF expression was observed in endothelial cells of early and advanced stage growth. NOS1 and NOS3 expressions showed a high increased value in stellate reticulum cells, and ameloblast and odontoblast clusters in advanced stage compared to early stage of development. The absence or only moderate positive reaction of NOS2 was detected in all the different tissues. Positive NOS2 expression showed in advanced stage of tissue development compared to early stage. The action of VEGF and NOS molecules are important mediators of angiogenesis during dental tissue development. VEGF high positive expression in stellate reticulum cells in the early stage of tooth development compared to the later stage and the other cell types, suggests a critical role of the stellate reticulum during dental embryo-morphogenesis.

Fiber reinforced composites orthodontic retainers.

AIM: Retention is the phase of orthodontic treatment that attempts to hold teeth in their corrected positions after orthodontic therapy is completed. The aim of this study was to consider fiber-reinforced composites (FRC) as a possible alternative to conventional multistranded stainless steel wire for retention through SEM analysis. METHODS: Two different FRC orthodontic retainers were investigated, i.e. Everstick® (Stick Tech Ltd, Turku, Finland) (type A, 24 samples), with a diameter of 0.76 mm made of glass fibers and a Young's modulus of elasticity of 28 gpa, and Ribbond® (Ribbond, Inc., Seattle, Washington, WA, USA) (type B, 24 samples), with ultra high molecular weight and with an high Young's modulus of elasticity by polyethylene fibers cold treated with plasma gas. Six groups were created: control groups A1 and B1, composed by 8 type A and 8 type B samples without impregnation and only with fluid resin before curing; groups A2 and B2, composed respectively by 8 type A and 8 type B samples impregnated with fluid resin Heliobond for 6 seconds; groups A3 and B3, composed respectively by 8 type A and 8 type B samples impregnated with fluid resin Heliobond for 6 minutes before curing. RESULTS: Cross- and lengthwise SEM analysis of the sectioned samples made showed that fiber without impregnation with fluid resin, before curing, showed interwoven and straight directed cylindrical fibers. The SEM analysis denoted that the two types of fiber shows structural characteristics differing in dimension, number, diameter and orientation of FRC without a preliminary treatment through impregnation of the fibers with fluid resin. CONCLUSION: An impregnation time of 6 seconds could considerably reduced voids, crazes and microcracks of the fibers, making them more resistant to the other oral and bacterial agents. A larger time of impregnation (6 minutes), with fluid resin before hardening, further enhances the morphological characteristics of the FRC.

Unilateral condylar hyperplasia: diagnosis, clinical aspects and operative treatment. A case report.

BACKGROUND: Condylar hyperplasia of the mandible is an uncommon idiopathic disorder of the jaw characterised by increased volume of the condyle, unilaterally or bilaterally, leading to facial asymmetry, mandibular deviation, malocclusion and articular dysfunction. CASE REPORT: The authors present one case of unilateral condylar hyperplasia of a 16-year-old patient affected by severe facial asymmetry. Conventional X-rays examinations, multislice spiral CT and bone SPECT were used for the final diagnosis of primary condyle hyperplasia. The patient was treated with a combined orthodontic and surgical approach. CONCLUSION: Treatment of condylar hyperplasia with a combined orthodontic and surgical approach including condylectomy yield good aesthetic and functional outcomes.

Osteogenic differentiation and gene expression of dental pulp stem cells under low-level laser irradiation: a good promise for tissue engineering.

The effects of low-level laser therapy (LLLT) has been the focus of recent studies as being assumed responsible for promoting photostimulatory and photobiomodulatory effects in vivo and in vitro, increasing cell metabolism, improving cell regeneration and invoking an anti-inflammatory response. A positive effect of LLLT on the bone proliferation of some cell types has been observed, but little is known about its effect on dental pulp stem cells (DPSCs). Here, we accurately describe the technical procedure to isolate mesenchymal DPSCs, and assay their osteogenic capacity when irradiated with an LLLT source. These preliminary results show that LLLT irradiation influences the in vitro proliferation of DPSCs and increases the expression of essential proteins for bone formation, although it is necessary to carry out further experiments on other cell types and to uniform the methodological designs.

Nitric oxide synthase evaluation in oral precancerous and cancerous lesions.

Nitric Oxide (NO) has been linked to several cardiovascular, neurological and immunological physiological and pathological functions. Several studies have shown that the eNOS, nNOS and iNOS effects on cancer cell growth and proliferation are related to the upregulation of the Wnt pathway and have a central role during metastasis development. Recent studies suggest that cancer cells undergo metabolic reprogramming, which drives cancer cell growth and progression. The aim of this study was to observe the NOS activity in the pathogenesis of oral precancerous and cancerous lesions. The results showed changes in eNOS activity levels, which increased from healthy oral mucosa to oral squamous cell carcinoma SCC, through different dysplasia levels. The iNOS activity levels increased in precancerous lesions compared to healthy mucosa, where iNOS was absent, while it decreased in SCC lesions. Moreover, a gradual increase of nNOS activity together with the progression of the lesions was also found. These results may suggest how NO could play a critical role during pathogenesis, growth and development of precancerous lesions to cancer degeneration.

Reconstruction of congenital isolated absent columella: a case report.

Congenital isolated absent columella is a rare event in population, with an aetiology that is still unclear. Reconstruction remains a challenging problem. A single case is presented with the description of an original single stage surgical technique to restore it.

STABLE: an innovative device for three-part maxillary osteotomy.

Le Fort I osteotomy of the maxilla continues to be one of the most common techniques used in the surgical correction of a variety of dento-midfacial deformities. Occasionaly, however, surgeons may encounter difficulties during three-pieces Le Fort I procedures because the surgical movements are also prone to adverse movement and subsequent relapse. This case report describes a 26 year old man, who presented with a skeletal Class III malocclusion and a transverse maxillary deficency. The malocclusion was corrected with a bilateral sagittal split osteotomy (BSSO) and a segmental Le Fort I and post-treatment stabilization was achieved with the STABLE (Surgical Tripartition Auxiliary Block Element), a new and innovative device usefull after three-part maxillary Le Fort I surgery.

Maxillary sinus augmentation procedures through equine-derived biomaterial or calvaria autologous bone: immunohistochemical evaluation of OPG/RANKL in humans.

Autologous bone is considered the gold standard for bone regeneration, even if different heterologous bone substitutes have been proposed to overcome the limits related to its use. The aim of this study was to analyze and to compare the molecular events switched on by autologous or heterologous bone graft insertion, focusing on TGFß1 expression and OPG/RANKL ratio, to analyze resorption process, and estimating graft vascularization, new bone tissue deposition and its mineralization, through VEGF, BSP and SPARC expression evaluation, respectively. Patients needing pre-prosthetic rehabilitation of the posterior maxilla were treated using an equine-derived biomaterial (Group 1) or calvaria autologous bone (Group 2), according to the morphology of the bone defect. Bone graft integration was evaluated on bone samples obtained from the treated areas at the moment of dental implant insertion, by morphological and immunohistochemical analyses for TGFß1, OPG, RANKL, VEGF, BSP, and SPARC expression. Morphological analysis shows the presence of biomaterial residual granules in Group 1, in parallel to a good integration between graft and host tissue. Moderate TGFß1 expression is seen in both Group 1 and Group 2. OPG/RANKL ratio appear higher in Group 1; VEGF expression appears very strong in Group 1 and strong in Group 2, while BSP and SPARC expression results weak in Group 1 and moderate in Group 2. Results reveal the good integration between both types of graft and the host tissue, even though autologous graft seems to produce a faster regenerative process, as evidenced by the different expression of the investigated molecules. According to these observations, the clinical use of heterologous particulate equine-derived biomaterial may ensure long-term predictability of implant-prosthetic rehabilitation, comparable to that obtained with autologous bone graft.

Nitric oxide synthase isoenzyme expression in human oral lichen planus.

The roles of nitric oxide (NO) synthase (NOS) enzyme in pathological mechanisms of the oral cavity are still incompletely understood. The aim of this study was to investigate the expression of the endothelial, neuronal and inducible isoforms of NOS (eNOS, nNOS and iNOS) in oral lichen planus (OLP) development in humans. OLP and healthy oral mucosa biopsies were taken for mRNA and protein analysis of NOS isoenzymes by RT-PCR, western blot and immunohistochemistry. The mRNA and protein levels of eNOS and nNOS were present in all samples, with a significant increase only for eNOS in OLP. The normal oral mucosa exhibited only small amounts of iNOS mRNA and protein, while it showed a significant rise in OLP samples. These results were confirmed by immunohistochemical analysis. Our findings suggest that NO produced by increased eNOS and iNOS expression may have circulatory and immune functions in the development of OLP.

Microarray evaluation of gene expression profiles in inflamed and healthy human dental pulp: the role of IL1beta and CD40 in pulp inflammation.

Dental pulp undergoes a number of changes passing from healthy status to inflammation due to deep decay. These changes are regulated by several genes resulting differently expressed in inflamed and healthy dental pulp, and the knowledge of the processes underlying this differential expression is of great relevance in the identification of the pathogenesis of the disease. In this study, the gene expression profile of inflamed and healthy dental pulps were compared by microarray analysis, and data obtained were analyzed by Ingenuity Pathway Analysis (IPA) software. This analysis allows to focus on a variety of genes, typically expressed in inflamed tissues. The comparison analysis showed an increased expression of several genes in inflamed pulp, among which IL1β and CD40 resulted of particular interest. These results indicate that gene expression profile of human dental pulp in different physiological and pathological conditions may become an useful tool for improving our knowledge about processes regulating pulp inflammation.

Three-dimensional tomographic mapping related to primary stability and structural miniscrew characteristics.

OBJECTIVES: To evaluate the maxilla, mandible, and cortical plates on computerized tomographic (CT) scans to achieve accurate three-dimensional bone thickness measurements. SETTING AND SAMPLE POPULATION: We selected the CT scans of 25 subjects (among 102), aged 18-58 years (10 men, 15 women), with nearly complete dentition. MATERIAL AND METHODS: We performed interradicular and bucco-lingual (including cortical plate thickness) measurements in dental areas distal to the canines in both alveolar arches, at three levels (5, 8, and 11 mm) from the alveolar ridge. RESULTS: The mean thicknesses of the cortical plates in the maxilla were 1.10 mm buccally and 1.27 mm on the palatal side (p < 0.05). In the mandible, cortical plates were 2.23 mm buccally and 2.02 mm lingually. Mandibular buccal and lingual cortical plates became thicker distally in the second and third molar areas. There was considerable variation in cortical thickness (from 0.25 to 5.50 mm). Based on interradicular distances, only 13% of measured sites in the maxilla were suitable for miniscrew insertion (≥3.3 mm), but 63% of sites were suitable in the mandible. CONCLUSION: This study showed considerable individual variation in bone thickness. Our data suggested that the palatal/lingual side may provide greater primary stability for miniscrews. The palatal area, between the second upper bicuspid and the first molar, appeared to be the most suitable area for tapered 7- to 9-mm miniscrews, starting at 1.5-2 mm from the alveolar crest.

The role of anti-cyclic citrullinated peptide antibody in periodontal disease.

The anti-Cyclic Citrullinated Peptide Antibodies (anti-CCP) are produced locally in the inflamed synovium of Rheumatoid arthritis (RA) patients, suggesting that citrullinated proteins are located in the inflamed synovium. In scientific literature were find periodontal bacterial DNA in serum and synovial fluid of RA with PD patients. RA and adult periodontitis share common pathogenetic mechanisms and immunologic and pathological findings RA. One oral pathogen strongly implicated in the pathogenesis of periodontal disease (PD), Porphyromonas. gingivalis, possesses a unique microbial enzyme, peptidylarginine deiminase (PAD), the human equivalent of which has been identified as a susceptibility factor for RA. Under this point of view, we speculate about the presence of anti-CCP antibodies in sera of PD with RA patients. We conducted this study to evaluate and compare the diagnostic and predictive utility of anti-CCP antibodies in patients with PD and patients with PD and RA. Anti-CCP antibody was not found in 21 sera (U/ml<10), included RA controls, while only 1 patient with chronic PD and probing depth of 7,1 mm was identified positive for anti-CCP (22.2 U/ml). Our data do not support a role for anti-CCP in diagnoses of periodontal disease.

Vascular endothelial growth factor and e-nitric oxide synthase-mediated regenerative response occurring upon autologous and heterologous bone grafts.

Bone regeneration procedures allow oral rehabilitation with dental implants also in edentulous ridges with severe bone atrophy. The integration of grafted materials with the host tissue can initiate regenerative, inflammatory and apoptotic response. Since molecular mechanisms exist at the basis of such response, the aim of this work is to investigate, by immunohistochemical analyses, the expression of proteins involved in the graft integration process, in parallel to clinical and histological modifications, occurring on sites treated with extraoral autologous bone graft deriving from the parietal region of the calvaria (eAB), intraoral autologous bone graft deriving from mandibular ramus (iAB) and heterologous bone graft from swine (hB) in human patients. In our study, the immunohistochemical expression of BSP, VEGF, eNOS in eAB samples was significantly higher (p < 0.05) compared to values recorded in iAB and hB samples. The inflammatory response, investigated by iNOS expression, was found lower in all autologous samples (eAB and iAB) compared to hB, at statistically significant values. Moreover, the expression of the pro-apoptotic molecule, Bax, resulted significantly lower (p < 0.05) in eAB than in iAB and hB samples. These values, together with the low number of apoptotic cells detected in autologous samples, suggest a good regenerative response when extraoral autologous bone graft is used in comparison to the response from the other grafts, and also suggest the use of calvaria graft as a predictable therapeutic procedure for repairing severe bone defects in oral and maxillofacial surgery, not only by clinical and biomechanical criteria, but also from a biomolecular aspect.