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Socket and ridge preservation from the three-dimensional perspective -A clinical study
Abstract
The healing process of the extraction socket results in a three-dimensional loss of volume of the alveolar ridge accompanied by crestolingual displacement of the mu-cogingival line. Combined hard and soft tissue resorptions of this kind can sometimes prevent the insertion of an implant in the prosthetically correct position without additional aug-mentative treatments. This prospective study evaluates in a split-mouth design the three-dimensional degree of preservation of the alveolar ridge following tooth extraction based on clinical and radiological examinations of 32 patients with 142 extractions with and without socket and ridge preservation (SP, RP) over a healing period of three to five months. In addition, the role of minimal invasive extraction techniques is closely considered in this context. Bio-Oss granules, Bio-Gide membrane and Stypro-Gelatine sponge were used for SP and RP depending on the indication. DVT, CT and coDiagnostiX software provided the basis for the three-dimensional radiological evaluation. The 3D radiological results obtained in the specified study period showed an approximately 65 % higher resorption rate in the control group without SP/RP than in the study group with SP/RP. The parameters of clinical width and thickness of the fixed gingiva and the alveolar ridge width can also be preserved significantly better in the study group than in the control group. A further noteworthy secondary effect is the approximately 50 % increase in local bone density after SP/RP, which positively influences the later primary stability of the implant. In the present study, after using SP/RP no additional augmen tative treatment was necessary in more than 90 % of cases during subsequent implantation in correct 3D position. Summarising and assuming minimal invasive extraction, it can be concluded that the bony alveolar ridge and the covering fixed gingiva can be significantly better preserved three-dimensionally using the presented surgical protocol for SP and RP.
... Shakibaie et al. demonstrated an indisputable need for socket preservation if delayed implant placement is planned [13]. It was shown that 6 out of 10 patients who did not receive socket preservation needed some kind of augmentation before implant therapy, while 1 out of 10 who did receive preservation therapy needed guided bone regeneration [13]. ...
... Shakibaie et al. demonstrated an indisputable need for socket preservation if delayed implant placement is planned [13]. It was shown that 6 out of 10 patients who did not receive socket preservation needed some kind of augmentation before implant therapy, while 1 out of 10 who did receive preservation therapy needed guided bone regeneration [13]. In this case, the treatment included preservation and delayed implant placement to avoid subsequent treatment. ...
Internal root resorption is a result of complex interaction of resorbing and inflammatory cells which are responsible for progressive destruction of intraradicular dentin along the middle and apical thirds of the canal walls due to osteoclastic action. It is a rare phenomenon that can manifest through a slow or rapid progression. If the IRR is extensive and the prognosis of endodontic treatment questionable, extraction of the tooth with socket preservation is recommended so that further complications can be avoided. After tooth extraction, a series of processes take place including scarring of the alveoli, with an inevitable three-dimensional loss of alveolar bone. Over the years many different techinques of socket preservation and socket grafting have been used, preserving the socket from collapse during normal healing process. A 20-year old female patient was referred by the endodontist to the Department of Oral Surgery, School of Dental Medicine, University of Zagreb because of a progressive internal root resorption of upper right lateral incisor and upper left central incisor. She reported trauma in the area of upper incisors in her childhood during playing with peers but without any further consequences until now. After analysing few different solutions, the patient agreed to have her teeth extracted with socket preservation and after healing period of 6 months for the implants to be placed in the extracted site. Dental implants (4.0 mm/12 mm for central incisor; 3.3 mm/12 mm for lateral incisor) were inserted in the positions of the missing teeth. The implants were loaded after 6 months with individual CAD/CAM made zirconia abutments with CAD/CAM made temporary acrylic crowns mainly for emergence profile modelling. Two lithium-disilicate crowns, supported with individual CAD/CAM zirconia abutments served as final restoration.
... The resorption of the alveolar structures is reduced firstly by stabilization of the intra-alveolar blood coagulum and secondly by augmentation of the cavity. If the bony extraction socket is damaged, the alveolar bone continuity is additionally restored with collagen membranes before/during its filling with biomaterials or autologous bone [5]. ...
Tooth socket preservation has become a key component of contemporary clinical dentistry. This term designates
alveolar preservation that achieved by immediate filling of the undamaged tooth socket with biomaterials.
Different types of bone substitutions and membranes have been utilized for socket augmentation. Our goal was
to evaluate the efficacy of the amniotic membrane, as a new material, on bone density in comparison with
conventional methods in this study. In this randomized clinical trial 75 patients (48 females and 27 males)
underwent mandibular molar extraction and socket preservation by using allograft bone in control group:
allograft bone with collagen membrane in group 1 and allograft bone with amniotic membrane in group 2. All
25 stages of socket preservation procedures in each group were done by the same surgeon and evaluated by the
same radiographic machine. The data were statistically analyzed by SPSS software, one-way ANOVA and Tukey
post-hoc tests. P value <0.05 was considered as significant. The results of this study showed that after 4 months
the mean density difference in extracted site was 1736.88 in control group; for patients who underwent socket
preservation with allograft and collagen membrane it was 1746.20 and in cases with allograft in addition
amniotic membrane it was 1762.48. The results demonstrated that, compared with control group, both collagen
membrane and amniotic membrane showed a higher bone density mean (P Value =/998 and P Value = /918),
but this difference was not statistically significant. Whereas amniotic membrane showed a higher bone density
than the collagen membrane, there are no significant differences between these two groups (P Value =/994).
Although socket preservation methods may be effective on alveolar bone contour
When performing a tooth extraction, imminent collapse of the tissue by resorption and remodeling of the socket is a natural occurrence. The procedure for the preservation of the alveolar ridge has been widely described in the dental literatures and aims to maintain hard and soft tissues in the extraction site for optimal rehabilitation either with conventional fixed or removable prosthetics or implant-supported prosthesis.
The objective of this investigation was to determine the fate of thin buccal bone encasing the prominent roots of maxillary anterior teeth following extraction. Resorption of the buccal plate compromises the morphology of the localized edentulous ridge and makes it challenging to place an implant in the optimal position for prosthetic restoration. In addition, the use of Bio-Oss as a bone filler to maintain the form of the edentulous ridge was evaluated. Nine patients were selected for the extraction of 36 maxillary anterior teeth. Nineteen extraction sockets received Bio-Oss, and seventeen sockets received no osteogenic material. All sites were completely covered with soft tissue at the conclusion of surgery. Computerized tomographic scans were made immediately following extraction and then at 30 to 90 days after heating so as to assess the fate of the buccal plates and resultant form of the edentulous sites. The results were assessed by an independent radiologist, with a crest width of 6 mm regarded as sufficient to place an implant. Those sockets treated with Bio-Oss demonstrated a loss of less than 20% of the buccal plate in 15 of 19 test sites (79%). In contrast, 12 of 17 control sockets (71%) demonstrated a loss of more than 20% of the buccal plate. In conclusion, the Bio-Oss test sites outperformed the control sites by a significant margin. No investigator was able to predict which site would be successful without the grafting material even though all were experienced clinicians. This leads to the conclusion that a patient has a significant benefit from receiving grafting materials at the time of extraction.
Preservation of alveolar bone volume following tooth extraction facilitates subsequent placement of dental implants and leads to an improved esthetic and functional prosthodontic result. The aim of the present study was to assess bone formation in the alveolus and the contour changes of the alveolar process following tooth extraction. The tissue changes after removal of a premolar or molar in 46 patients were evaluated in a 12-month period by means of measurements on study casts, linear radiographic analyses, and subtraction radiography. The results demonstrated that major changes of an extraction site occurred during 1 year after tooth extraction.
Conventional dentoalveolar osseous reconstruction often involves the use of grafting materials with or without barrier membranes. The purpose of this study was to evaluate the efficacy of bone induction for the placement of dental implants by two concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on a bioabsorbable collagen sponge (ACS) compared to placebo (ACS alone) and no treatment in a human buccal wall defect model following tooth extraction.
Eighty patients requiring local alveolar ridge augmentation for buccal wall defects (> or =50% buccal bone loss of the extraction socket) of the maxillary teeth (bicuspids forward) immediately following tooth extraction were enrolled. Two sequential cohorts of 40 patients each were randomized in a double-masked manner to receive 0.75 mg/ml or 1.50 mg/ml rhBMP-2/ACS, placebo (ACS alone), or no treatment in a 2:1:1 ratio. Efficacy was assessed by evaluating the amount of bone induction, the adequacy of the alveolar bone volume to support an endosseous dental implant, and the need for a secondary augmentation.
Assessment of the alveolar bone indicated that patients treated with 1.50 mg/ml rhBMP-2/ACS had significantly greater bone augmentation compared to controls (P < or =0.05). The adequacy of bone for the placement of a dental implant was approximately twice as great in the rhBMP-2/ACS groups compared to no treatment or placebo. In addition, bone density and histology revealed no differences between newly induced and native bone.
The data from this randomized, masked, placebo-controlled multicenter clinical study demonstrated that the novel combination of rhBMP-2 and a commonly utilized collagen sponge had a striking effect on de novo osseous formation for the placement of dental implants.
Die membrangeschuetzte Knochenregeneration fuehrt zur Erweiterung der Indikation enossaler Implantate bei Alveolarfortsatzdefekten. Bei bislang eingesetzten Membranen wird eine barrierefunktion ueber einen Zeitraum von etwa 4 Monaten angestrebt. In dieser Zeit koennen vorzeitige Expositionen und bakterielle Infektionen der poroesen membran auftreten und zu Augmentationsmisserfolgen fuehren. Eine neue nicht-resorbierbare Membran (TefGen-FD) aus verdichtetem Polytetraflourethylenkommt ohne primaere weichteildeckung ueber dem Defekt zur Anwendung, verbleibt lediglich drei Wochen in situ und wird dann entfernt. Ziel der vorliegenden Untersuchung war die Beurteilung dieser membran bezueglich des erhalts der Dimensionierung des Kieferkamms nach Zahnextraktionen in einer randomisierten prospektiven Studie an 39 Patienten. Zu vergleichende Zielparameter waren dabei die Differenzen aus den Ausgangswerten vor der Extraktion und den nach 4 Monaten gemessenen Werten der Alveolarkammhoehe, -breite sowie der Breite der vestibulaeren fixierten Gingiva. Signifikante Unterschiede (0.001<p<0.006) dieser Parameter vor und nach Zahnextraktion zwischen der Kontrollgruppe und der Patientengruppe unter Behandlung mit der TefGen-FDmMembranzeigten, dass nach Zahnextraktionen die Kieferkammkonfiguration und die Breite der vestibulaeren fixierten Gingiva bei Anwendung der TefGen-FD-Membran erhalten bleibt.
Tooth extraction is associated with loss of the alveolar bone and surrounding keratinised gingiva. The author illustrates a treatment protocol for the maximum and most predictable preservation outcome
Implant placement in naturally healed extraction sockets often is impossible, unless simultaneous or even preimplantological bone augmentation is performed. However, simultaneous implant insertion and bone augmentation require high surgical skills and sometimes cause problems in wound healing. The proposed treatment concept for extraction sockets in which immediate implant placement cannot be achieved includes filling of the socket with non-resorbable bone graft materials (socket preservation), healing of several months, and late implant placement without simultaneous augmentation procedures. The separation of the time points of bone augmentation and implant placement reduces problems with wound healing, facilitates an easier soft tissue management, and simplifies the surgical demands.
The purpose of this study was to evaluate: (1) the surgical protocol, effectiveness, and reliability for vertical ridge augmentation using a new titanium-reinforced membrane and osseointegrated implants; and (2) the histologic characteristics of the interface between a pure titanium implant and newly regenerated human bone. Five patients received 15 conical Brånemark-type implants in six different surgical sites requiring vertical augmentation. The implants protruded 4 to 7 mm from the bone crest. Pure titanium miniscrews (1.3 x 10 mm) were positioned distally to the implants, protruding 3 to 4 mm from the bone level. The implants and the miniscrews were covered with a titanium-reinforced membrane, and the flaps were sutured. Membranes were removed at the stage 2 surgery after 9 months of healing. Measurements of biopsy specimens showed a gain in bone height from 3 to 4 mm. Histologic examination showed that all retrieved miniscrews were in direct contact with bone. Histomorphometric analysis of bone contact gave a mean value of 42.5 +/- 3.6% for five of the six examined miniscrews. The results suggest that the placement of implants protruding 3 to 4 mm from the top of resorbed bone surfaces may result in vertical bone regeneration to the top of the implant cylinder and that the regenerated bone is able to osseointegrate pure titanium implants.
The purpose of the present clinical study was to evaluate the 5-year results of the first 12 implants inserted at the University of Berne in regenerated bone following successful ridge augmentation with the membrane technique. The patients were recalled and examined with clinical and radiographic parameters routinely utilized in prospective studies with standard implants in non-regenerated bone. Based on clinical and radiographic findings, all 12 implants were considered successfully integrated according to strict criteria of success. The detailed analysis of clinical parameters revealed no differences to results of prospective studies on standard implants in non-regenerated bone. All implants demonstrated ankylotic stability which was confirmed by a mean Periotest value of -2.08. The radiographic analysis showed stable bone crest levels with a mean bone loss between the 1- and 5-year examination of 0.30 mm. However, 2 implants exhibited a bone loss of more than 1 mm between the 1- and 5-year examination. Therefore, the prognosis of these 2 implants seems questionable at the present time. It can be concluded that bone regenerated with the membrane technique reacts to implant placement like non-regenerated bone, since all 12 implants achieved successful tissue integration with functional ankylosis. Furthermore, this bone is also load-bearing, since all 12 implants maintained osseointegration over a 5-year period.
This retrospective multicenter study analyzed 526 implants placed and loaded in regenerated bone. Both autogenous and allogeneic bone grafts were used in combination with a barrier membrane to reconstruct bone using either a simultaneous or staged approach. Implants were followed from 6 to more than 74 months postloading. Eight of the implants were lost, for a success rate of 97.5%. The type of graft material did not affect the clinical success of the implants, nor did the use of submerged versus nonsubmerged implants or a staged versus a simultaneous approach. In conclusion, regenerated bone reacted to implant placement in a manner that was clinically similar to native bone.
The purpose of this study was to evaluate the clinical effectiveness of a bioabsorbable membrane made of glycolide and lactide polymers in preserving alveolar ridges following tooth extraction using a surgical technique based on the principles of guided bone regeneration. Sixteen patients requiring extractions of 2 anterior teeth or bicuspids participated in the study (split-mouth design). Following elevation of buccal and lingual full-thickness flaps and extraction of teeth, experimental sites were covered with bioabsorbable membranes; control sites did not receive any membrane. Titanium pins served as fixed reference points for measurements. Flaps were advanced in order to achieve primary closure of the surgical wound. No membrane became exposed in the course of healing. Reentry surgeries were performed at 6 months. Results showed that experimental sites presented with significantly less loss of alveolar bone height, more internal socket bone fill, and less horizontal resorption of the alveolar bone ridge. This study suggests that treatment of extraction sockets with membranes made of glycolide and lactide polymers is valuable in preserving alveolar bone in extraction sockets and preventing alveolar ridge defects.
To study dimensional alterations of the alveolar ridge that occurred following tooth extraction as well as processes of bone modelling and remodelling associated with such change.
Twelve mongrel dogs were included in the study. In both quadrants of the mandible incisions were made in the crevice region of the 3rd and 4th premolars. Minute buccal and lingual full thickness flaps were elevated. The four premolars were hemi-sected. The distal roots were removed. The extraction sites were covered with the mobilized gingival tissue. The extractions of the roots and the sacrifice of the dogs were staggered in such a manner that all dogs contributed with sockets representing 1, 2, 4 and 8 weeks of healing. The animals were sacrificed and tissue blocks containing the extraction socket were dissected, decalcified in EDTA, embedded in paraffin and cut in the buccal-lingual plane. The sections were stained in haematoxyline-eosine and examined in the microscope.
It was demonstrated that marked dimensional alterations occurred during the first 8 weeks following the extraction of mandibular premolars. Thus, in this interval there was a marked osteoclastic activity resulting in resorption of the crestal region of both the buccal and the lingual bone wall. The reduction of the height of the walls was more pronounced at the buccal than at the lingual aspect of the extraction socket. The height reduction was accompanied by a "horizontal" bone loss that was caused by osteoclasts present in lacunae on the surface of both the buccal and the lingual bone wall.
The resorption of the buccal/lingual walls of the extraction site occurred in two overlapping phases. During phase 1, the bundle bone was resorbed and replaced with woven bone. Since the crest of the buccal bone wall was comprised solely of bundle this modelling resulted in substantial vertical reduction of the buccal crest. Phase 2 included resorption that occurred from the outer surfaces of both bone walls. The reason for this additional bone loss is presently not understood.
The current experiments had three aims (i) to determine whether the absence of the periodontal ligament (PDL) may alter features of the healing of an extraction socket, (ii) to examine if there were differences in the proportion of different tissues in resolved extraction sockets and surgically produced defects after 3 months of healing, (iii) to study the influence of different biomaterials on the healing of surgically produced bone defects.
Extraction sites: In five dogs, the 4th mandibular pre-molars were hemi-sected and the distal roots were removed. The extraction socket of one of the pre-molars was instrumented to eliminate all remnants of the PDL tissue. The socket of the contra-lateral pre-molar was left without instrumentation. The dogs were sacrificed after 3 months of healing. Defect sites: In five dogs, the pre-molars and 1st molars on both sides of the mandible were first removed and 3 months of healing allowed. After this interval three standardized cylindrical defects were prepared in each side of the mandible. The defects were 3.5 mm in diameter and 8 mm deep. In each quadrant one defect was grafted with Bio-Oss Collagen, one with Collagen Sponge and one defect was left non-grafted. The dogs were sacrificed 3 months after the grafting procedure.
Extraction sites: The two categories of extraction sockets did not differ with respect to gross morphological features. The tissue of the extraction sites, apical of a newly formed bone bridge, was dominated by bone marrow. Few trabeculae of lamellar bone were also present. Defect sites: The non-augmented defect was sealed by a hard-tissue bridge. In the central and apical portions of the defect bone marrow made up about 61%, and mineralized bone 39% of the tissues. The invagination of the surface of this crestal bone was 0.8+/-0.3 mm. The defect augmented with Collagen Sponge was covered by a hard-tissue bridge 38% of the tissue within the defect was made up of bone marrow while the remaining 62% was occupied by mineralized bone. The invagination of the hard-tissue bridge was on the average 0.6+/-0.1 mm. In defects augmented with Bio-Oss Collagen the biomaterial occupied a substantial portion of the tissue volume. Eighty-five percent of the periphery of the Bio-Oss particles were found to be in direct contact with newly formed mineralized bone. Woven bone and bone marrow made up 47% and 26% of the newly formed tissue. The invagination of the most coronal part of the bone defect was 0.1+/-0.1 mm.
Sockets that following tooth removal had their PDL tissue removed exhibited similar features of healing after 3 months as sockets which had the PDL retained. The tissues present in an extraction site appeared to be more mature than those present in a surgically produced defect of similar dimension. The Bio-Oss Collagen augmented defect exhibited less wound shrinkage than the non-augmented defect.
The objective of this systematic review was to critically evaluate marginal soft-tissue aspects at implants subjected to immediate loading or immediate restoration.
An electronic Medline search from 1966 up to August 2005 was conducted to identify prospective and retrospective studies on immediate implant loading. The search strategy was complemented by hand searching in peer-reviewed journals. Studies reporting on soft-tissue aspects at implants subjected to immediate loading or immediate restoration and with a follow-up time of at least 1 year were included. Assessment of identified studies and data extraction was performed independently by two reviewers. An attempt was made to isolate and categorize studies with similar protocols in order to identify trends and relevant factors. Variables that were considered included marginal and interproximal soft-tissue stability, marginal plaque accumulation, probing depth, bleeding on probing, peri-implant mucositis and peri-implantitis.
From an initial yield of 581 titles, 240 articles were selected for text analysis, finally resulting in 17 studies that met the inclusion criteria. Six studies on immediate implant loading or restoration were controlled studies, whereas the remainder was prospective case series. Seven studies reported on a 1-year data, and the longest follow-up within the included studies was 4 years. The total number of patients treated within the 17 studies was 432 including a total 706 implants studied. Overall, the articles reported on many different procedures and follow-up times, time points and evaluated soft-tissue parameters varied considerably between the different articles.
Within the limits of the evaluated data it can be cautiously concluded that once immediately loaded or restored implants integrate successfully, they appear to show a soft-tissue reaction with regard to periodontal as well as morphologic aspects comparable with those of conventionally loaded implants. However, follow-up periods are generally short, number of patients and/or implants per study are few, and most studies present only limited data on peri-implant soft-tissue evaluation. More accurate long-term studies with a stronger study design (i.e., RCT) reporting more detailed on treatment and follow-up protocols are required to allow for proper comparisons and conclusions.
Lateral ridge augmentations are traditionally performed using autogenous bone grafts to support membranes for guided bone regeneration (GBR). The bone-harvesting procedure, however, is accompanied by considerable patient morbidity.
The aim of the present study was to test whether or not resorbable membranes and bone substitutes will lead to successful horizontal ridge augmentation allowing implant installation under standard conditions.
Twelve patients in need of implant therapy participated in this study. They revealed bone deficits in the areas intended for implant placement. Soft tissue flaps were carefully raised and blocks or particles of deproteinized bovine bone mineral (DBBM) (Bio-Oss) were placed in the defect area. A collagenous membrane (Bio-Gide) was applied to cover the DBBM and was fixed to the surrounding bone using poly-lactic acid pins. The flaps were sutured to allow for healing by primary intention.
All sites in the 12 patients healed uneventfully. No flap dehiscences and no exposures of membranes were observed. Nine to 10 months following augmentation surgery, flaps were raised in order to visualize the outcomes of the augmentation. An integration of the DBBM particles into the newly formed bone was consistently observed. Merely on the surface of the new bone, some pieces of the grafting material were only partly integrated into bone. However, these were not encapsulated by connective tissue but rather anchored into the newly regenerated bone. In all of the cases, but one, the bone volume following regeneration was adequate to place implants in a prosthetically ideal position and according to the standard protocol with complete bone coverage of the surface intended for osseointegration. Before the regenerative procedure, the average crestal bone width was 3.2 mm and to 6.9 mm at the time of implant placement. This difference was statistically significant (P<0.05, Wilcoxon's matched pairs signed-rank test).
After a healing period of 9-10 months, the combination of DBBM and a collagen membrane is an effective treatment option for horizontal bone augmentation before implant placement.
The objective of the present experiment was to evaluate the effect on hard tissue modeling and remodeling of the placement of a xenograft in fresh extraction sockets in dogs. Five mongrel dogs were used. Two mandibular premolars (4P4) were hemisected in each dog, and the distal roots were carefully removed. In one socket, a graft consisting of Bio-Oss Collagen (Geistlich) was placed, whereas the contralateral site was left without grafting. After 3 months of healing, the dogs were euthanized and biopsies sampled. From each experimental site, four ground sections (two from the mesial root and two from the healed socket) were prepared, stained, and examined under the microscope. The presence of Bio-Oss Collagen failed to inhibit the processes of modeling and remodeling that took place in the socket walls following tooth extraction. However, it apparently promoted de novo hard tissue formation, particularly in the cortical region of the extraction site. Thus, the dimension of the hard tissue was maintained and the profile of the ridge was better preserved. The placement of a biomaterial in an extraction socket may promote bone modeling and compensate, at least temporarily, for marginal ridge contraction.
Die Versorgung der Extraktionsalveole aus prothetischer Sicht -Detailaspekte für ästhetisch relevante Situationen
- O Zuhr
- S Fickl
- H Wachtel
- W Bolz
- M B Hürzeler
Zuhr O, Fickl S, Wachtel H, Bolz W,
Hürzeler MB: Die Versorgung der Extraktionsalveole aus prothetischer
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Rekonstruktion und verzögerte Sofortrekonstruktion der Extraktionsalveole
- H Terheyden
Terheyden H: Rekonstruktion und verzögerte Sofortrekonstruktion der Extraktionsalveole. Implantologie 2006;
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Chirurgische Versorgung der Extraktionsalveole
- H Terheyden
- G Iglhaut
Terheyden H, Iglhaut G: Chirurgische
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Zahnärztl Impl 2006;22:42-45
Vertical ridge augmentation by expanded-polytetrafluorethylene membrane and a combination of intraoral autogenous bone graft and deproteinized anorganic bovine bone (Geistlich Bio-Oss)
- M Simion
- F Frontane
- G Rasperini
- C Maiorana
Simion M, Frontane F, Rasperini G,
Maiorana C: Vertical ridge augmentation by expanded-polytetrafluorethylene membrane and a combination of intraoral autogenous bone graft and deproteinized anorganic bovine bone
(Geistlich Bio-Oss). Clin Oral Implants
Res 2007;18:620-9
A soft tissue punch technique
- R E Jung
- D W Siegenthaler
- C H Hämmerle
Jung RE, Siegenthaler DW, Hämmerle
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