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Localized alveolar ridge augmentation before orthodontic treatment
C o p y r i g h t © M u n k s g a a r d 1994
Int. J. Oral Maxillof~m Surg. 1994; 23." 226 228 Printed in Denmark. All rights reserved
InternationalJoumalof
Oral& MaxillofaciaISurgery I S S N 0901-5027
Localized alveolar ridge augmentation before orthodontic treatment
Thomas Mayer 1, Efthimia K. Basdra 2, Gerda Komposch 2, Hans J6rg Staehle 1 1Poliklinik fLir Zahnerhaltungskunde and 2poliklinik for Kieferorthop&die, Ruprecht-Karls-U niversitgtt Heidelberg, D-69120 Heidelberg, Germany
A case report T. Mayer, E. K. Basdra, G. Komposch, H. J. Staehle: Localized alveolar ridge augmentation before orthodontic treatment. A case report. Int. or. Oral Maxillofac. Surg. 1994," 23: 22~228. © Munksgaard, 1994 Abstract. Extraction spaces are usually characterized by narrow, atrophic alveolar ridges, which make it difficult to move teeth orthodontically within these areas. Guided tissue regeneration is often used for alveolar ridge augmentation in implantology. In the case presented, localized alveolar ridge augmentation was performed as a preliminary procedure before orthodontic closure of an edentulous space. Guided tissue regeneration enhances the possibilities of orthodontic treatment in adult patients.
Zusammenfassung. Zu geringe H6he und Breite des Alveolarfortsatzes lassen die Bewegung von Z/ihnen in zahnlose Kieferabschnitte h/iufig nicht zu. Das Verfahren der gesteuerten Geweberegeneration erm6glicht die Augmentation kollabierter Kieferkammbereiche. In dem vorliegenden Fallbericht soll das Vorgehen der lokalen Kieferkammaugmentation als vorbereitende Magnahme vor kieferorthop/idischem Lfickenschlug vorgestellt und diskutiert werden. Die Methode der gesteuerten Geweberegeneration erweitert die M6glichkeiten der kieferorthopfidischen Therapie.
Key words: alveolar ridge augmentation; bone regeneration; orthodontics. Accepted for publication 10 March 1994
¢.
The principle of guided tissue regeneration (GTR) allows the periodontal ligament and bone to proliferate into a preformed space 6. The placement of an expanded polytetrafluoroethylene (PTFE) membrane over a detached root surface prevents gingival tissues from refilling the preformed space under the membrane. Thus, slower migrating periodontal ligament and bone cells a r e allowed t o repopulate the osseous defect. In implantology, this principle helps to refill bony defects or fenestrations around dental implants1 5,7. Primary
wound closure prevents epithelium and connective tissue from growing into the defect without requiring the regeneration of a periodontal ligament. These conditions result in a higher degree of bone regeneration than in periodontal defects.. In edentulous areas, bone augmentation can be used as a preliminary procedure to enlarge a narrow alveolar ridge, hence facilitating implant placement3,7. In orthodontics, sufficiently wide alveolar ridges are required for tooth movement. In this case report, the use
of G T R for augmentation of a deficient alveolar ridge area is presented as a preliminary procedure before orthodontic treatment is started.
Case report A 19-year-old wQman presented in the department of orthodontics with a skeletal class III relationship. An alternative procedure to combined surgical-orthodontic treatment seemed to be retraction of the lower anteriors by closing the existing spaces in the region 34 and 44. The deficient alveolar ridges presented a problem for space closure (Fig. 1) and had to be widened to enable tooth move-
Alveolar ridge augmentation
227
mentation is shown in Fig. 3. Eight months after removal of the membranes, orthodontic treatment was started, and spaces were closed after 19 months.
Discussion
Fig. l. Narrow alveolar ridge in bicuspid region. Fig. 2. Widened alveolar ridge 6 months after membrane placement (arrows point to new bone formation).
Fig. 3. Sections of casts perpendicular to alveolar ridge. Left side: before augmentation; right side: 14 months after augmentation.
ment (Fig. 2). The guided tissue regeneration approach was chosen for the augmentation. At the beginning of the treatment, the patient was instructed in proper plaque control and oral hygiene procedures. Examination of pocket depths and determination of plaque and gingival indices were done presurgically. The gingival tissues were not inflamed, and there was no detectable loss of attachment. Under local anaesthesia, mucoperiosteal flaps were prepared in the region 34 and 44 after marginal incisions. In the edentulous areas, the incisions were extended lingually. Vertical incisions were not necessary. The cortical bone was perforated several times with a carbide burr to facilitate the migration of bone marrow into the preformed space. For each area an expanded PTFE membrane was trimmed with scissors such that the border of the stiffer membrane portion was lying in direct contact with the bone. Around the
adjacent teeth uncovered borders were allowed to remain, to ensure primary wound closure and to reduce the risk of infection. The space beneath the membranes was wide enough to accommodate the designated teeth. Additional measures for enlarging the spaces were therefore not required. During adaption of the membranes, the preformed spaces filled with blood. The flaps were repositioned after periosteal incisions and sutured to obtain primary closure and to prevent collapse of the underlying membrane. The patient was instructed to rinse her mouth twice daily for 2 weeks with a 0.1% chlorhexidine solution. Postoperative recalls were done weekly with plaque control for 1 month. The wound healing was uneventful. The sutures were removed after 2 weeks. The reentry operation was done after 6 months. New bone formation was noticed beneath the membranes (Fig. 2). The extent of the ridge aug-
O r t h o d o n t i c t o o t h m o v e m e n t into edentulous ridge areas requires sufficient b o n e volume. T h e resorption after t o o t h extraction results in b o n e loss a n d narrowing of the alveolar ridge. In these sites, o r t h o d o n t i c t r e a t m e n t is n o t feasible. I n implantology, alveolar ridge augm e n t a t i o n with G T R is used as a preliminary or simultaneous p r o c e d u r e for alveolar ridge widening to enable imp l a n t p l a c e m e n t 3'4'7. BUSER et al. 3 present several requirements for successful treatment. Secondary w o u n d healing leads to a n adverse surgical result a n d often forces the p r e m a t u r e r e m o v a l o f the m e m b r a n e . Accurate w o u n d closure, incisions beside the alveolar process, a n d n o n t r a u m a t i c p r e p a r a t i o n m e t h o d s are required. A proper, bioinert m e m b r a n e , which can be a d a p t e d a n d stabilized in the p r o v i d e d position, serves as a physical barrier. T h e m e m b r a n e b o r d e r s m u s t be in direct c o n t a c t with the alveolar bone, to avoid gingival a n d connective tissues growing into the p r e f o r m e d space. Screws are available to stabilize the m e m b r a n e in the desired position. A l v e o l a r ridge a u g m e n t a t i o n can be expected only if a space u n d e r the m e m b r a n e is created a n d preserved. Collapse o f the m e m b r a n e f r o m the pressure o f the covering tissues or o t h e r reasons can be avoided by using a stiff m a t e r i a l and, if necessary, m e m b r a n e pillars. H o m o l o g o u s a n d a u t o l o g o u s b o n e grafts, alloplastic materials, or screw systems c a n be used as m e m b r a n e pillars. T h e use of alloplastic materials is p r o h i b i t e d in c o m b i n a t i o n with o r t h o d o n t i c t r e a t m e n t , because r e s o r p t i o n of the graft is n o t predictable a n d r o o t res o r p t i o n m a y be expected. In the present case, the rigidity of the m e m b r a n e a n d the b o n e structure was sufficient for correct p l a c e m e n t o f the m e m b r a n e . Additional fixation with pillars was therefore n o t necessary. I m p l a n t p l a c e m e n t usually follows 6 - 9 m o n t h s after removal o f the m e m brane. T h e new b o n e is usually suitable for the p l a c e m e n t o f implants. The biologic reaction within this tissue to o r t h o d o n t i c t r e a t m e n t is n o t k n o w n . T h e ort h o d o n t i c t r e a t m e n t in the present case b e g a n ,8 m o n t h s after r e m o v a l of the
228
Mayer et al.
Fig. 4. Radiographs before (left side) and after (right side) treatment. Horizontal or vertical bone loss after space closure was not detectable.
membranes. O r t h o d o n t i c space closure was successful, and no a t t a c h m e n t loss was observed clinically or radiographically (Fig. 4). Localized alveolar ridge augmentation with G T R can be used as a preliminary procedure before o r t h o d o n tic treatment. F u r t h e r clinical studies are needed with long observation periods and statistical data to evaluate
whether or n o t this procedure can be used as a routine t r e a t m e n t m e t h o d .
References 1. ARORA BK, MACDONALD WORLEY C, Gvxxu RL, LASKINDM. Bone formation over partially exposed implants using guided tissue regeneration. J Oral Maxillofac Surg 1992: 50: 1060-5.
2. BECKERW, BECKERBE. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: surgical techniques and case reports. Int J Periodont Rest Dent 1990: I0:377 91. 3. BUSERD, DULA K, BELSERU, HIRT HP, BERTHOLD H. Lokaler Kieferkammaufbau mit der gesteuerten Geweberegeneration. I. Operatives Vorgehen im Oberkiefer. Int J Par Rest Zahnheilkd 1993: 13: 29-45. 4. JOVANOVIC SA, SPIEKERMANNH, RICHTER E. Bone regeneration around titanium dental implants in dehisced defect sites: a clinical study, lnt J Oral Maxillofac Implants 1992: 7:233 45. 5. LAZZARA RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodont Rest Dent 1989: 5: 333-43. 6. NYMANS, LINDHEJ, KARRINGT, RYLANDER H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982: 9: 290-6. 7. SHANAMANRH. The use of guided tissue regeneration to facilitate ideal prosthetic placement of implants. Int J Periodont Rest Dent 1992: 12: 257-65.
Address:
Dr Thomas Mayer Poliklinik fiir Zahnerhaltungskunde Im Neuenheimer Feld 400 D-69120 Heidelberg Germany
Int. J. Oral Maxillof~m Surg. 1994; 23." 226 228 Printed in Denmark. All rights reserved
InternationalJoumalof
Oral& MaxillofaciaISurgery I S S N 0901-5027
Localized alveolar ridge augmentation before orthodontic treatment
Thomas Mayer 1, Efthimia K. Basdra 2, Gerda Komposch 2, Hans J6rg Staehle 1 1Poliklinik fLir Zahnerhaltungskunde and 2poliklinik for Kieferorthop&die, Ruprecht-Karls-U niversitgtt Heidelberg, D-69120 Heidelberg, Germany
A case report T. Mayer, E. K. Basdra, G. Komposch, H. J. Staehle: Localized alveolar ridge augmentation before orthodontic treatment. A case report. Int. or. Oral Maxillofac. Surg. 1994," 23: 22~228. © Munksgaard, 1994 Abstract. Extraction spaces are usually characterized by narrow, atrophic alveolar ridges, which make it difficult to move teeth orthodontically within these areas. Guided tissue regeneration is often used for alveolar ridge augmentation in implantology. In the case presented, localized alveolar ridge augmentation was performed as a preliminary procedure before orthodontic closure of an edentulous space. Guided tissue regeneration enhances the possibilities of orthodontic treatment in adult patients.
Zusammenfassung. Zu geringe H6he und Breite des Alveolarfortsatzes lassen die Bewegung von Z/ihnen in zahnlose Kieferabschnitte h/iufig nicht zu. Das Verfahren der gesteuerten Geweberegeneration erm6glicht die Augmentation kollabierter Kieferkammbereiche. In dem vorliegenden Fallbericht soll das Vorgehen der lokalen Kieferkammaugmentation als vorbereitende Magnahme vor kieferorthop/idischem Lfickenschlug vorgestellt und diskutiert werden. Die Methode der gesteuerten Geweberegeneration erweitert die M6glichkeiten der kieferorthopfidischen Therapie.
Key words: alveolar ridge augmentation; bone regeneration; orthodontics. Accepted for publication 10 March 1994
¢.
The principle of guided tissue regeneration (GTR) allows the periodontal ligament and bone to proliferate into a preformed space 6. The placement of an expanded polytetrafluoroethylene (PTFE) membrane over a detached root surface prevents gingival tissues from refilling the preformed space under the membrane. Thus, slower migrating periodontal ligament and bone cells a r e allowed t o repopulate the osseous defect. In implantology, this principle helps to refill bony defects or fenestrations around dental implants1 5,7. Primary
wound closure prevents epithelium and connective tissue from growing into the defect without requiring the regeneration of a periodontal ligament. These conditions result in a higher degree of bone regeneration than in periodontal defects.. In edentulous areas, bone augmentation can be used as a preliminary procedure to enlarge a narrow alveolar ridge, hence facilitating implant placement3,7. In orthodontics, sufficiently wide alveolar ridges are required for tooth movement. In this case report, the use
of G T R for augmentation of a deficient alveolar ridge area is presented as a preliminary procedure before orthodontic treatment is started.
Case report A 19-year-old wQman presented in the department of orthodontics with a skeletal class III relationship. An alternative procedure to combined surgical-orthodontic treatment seemed to be retraction of the lower anteriors by closing the existing spaces in the region 34 and 44. The deficient alveolar ridges presented a problem for space closure (Fig. 1) and had to be widened to enable tooth move-
Alveolar ridge augmentation
227
mentation is shown in Fig. 3. Eight months after removal of the membranes, orthodontic treatment was started, and spaces were closed after 19 months.
Discussion
Fig. l. Narrow alveolar ridge in bicuspid region. Fig. 2. Widened alveolar ridge 6 months after membrane placement (arrows point to new bone formation).
Fig. 3. Sections of casts perpendicular to alveolar ridge. Left side: before augmentation; right side: 14 months after augmentation.
ment (Fig. 2). The guided tissue regeneration approach was chosen for the augmentation. At the beginning of the treatment, the patient was instructed in proper plaque control and oral hygiene procedures. Examination of pocket depths and determination of plaque and gingival indices were done presurgically. The gingival tissues were not inflamed, and there was no detectable loss of attachment. Under local anaesthesia, mucoperiosteal flaps were prepared in the region 34 and 44 after marginal incisions. In the edentulous areas, the incisions were extended lingually. Vertical incisions were not necessary. The cortical bone was perforated several times with a carbide burr to facilitate the migration of bone marrow into the preformed space. For each area an expanded PTFE membrane was trimmed with scissors such that the border of the stiffer membrane portion was lying in direct contact with the bone. Around the
adjacent teeth uncovered borders were allowed to remain, to ensure primary wound closure and to reduce the risk of infection. The space beneath the membranes was wide enough to accommodate the designated teeth. Additional measures for enlarging the spaces were therefore not required. During adaption of the membranes, the preformed spaces filled with blood. The flaps were repositioned after periosteal incisions and sutured to obtain primary closure and to prevent collapse of the underlying membrane. The patient was instructed to rinse her mouth twice daily for 2 weeks with a 0.1% chlorhexidine solution. Postoperative recalls were done weekly with plaque control for 1 month. The wound healing was uneventful. The sutures were removed after 2 weeks. The reentry operation was done after 6 months. New bone formation was noticed beneath the membranes (Fig. 2). The extent of the ridge aug-
O r t h o d o n t i c t o o t h m o v e m e n t into edentulous ridge areas requires sufficient b o n e volume. T h e resorption after t o o t h extraction results in b o n e loss a n d narrowing of the alveolar ridge. In these sites, o r t h o d o n t i c t r e a t m e n t is n o t feasible. I n implantology, alveolar ridge augm e n t a t i o n with G T R is used as a preliminary or simultaneous p r o c e d u r e for alveolar ridge widening to enable imp l a n t p l a c e m e n t 3'4'7. BUSER et al. 3 present several requirements for successful treatment. Secondary w o u n d healing leads to a n adverse surgical result a n d often forces the p r e m a t u r e r e m o v a l o f the m e m b r a n e . Accurate w o u n d closure, incisions beside the alveolar process, a n d n o n t r a u m a t i c p r e p a r a t i o n m e t h o d s are required. A proper, bioinert m e m b r a n e , which can be a d a p t e d a n d stabilized in the p r o v i d e d position, serves as a physical barrier. T h e m e m b r a n e b o r d e r s m u s t be in direct c o n t a c t with the alveolar bone, to avoid gingival a n d connective tissues growing into the p r e f o r m e d space. Screws are available to stabilize the m e m b r a n e in the desired position. A l v e o l a r ridge a u g m e n t a t i o n can be expected only if a space u n d e r the m e m b r a n e is created a n d preserved. Collapse o f the m e m b r a n e f r o m the pressure o f the covering tissues or o t h e r reasons can be avoided by using a stiff m a t e r i a l and, if necessary, m e m b r a n e pillars. H o m o l o g o u s a n d a u t o l o g o u s b o n e grafts, alloplastic materials, or screw systems c a n be used as m e m b r a n e pillars. T h e use of alloplastic materials is p r o h i b i t e d in c o m b i n a t i o n with o r t h o d o n t i c t r e a t m e n t , because r e s o r p t i o n of the graft is n o t predictable a n d r o o t res o r p t i o n m a y be expected. In the present case, the rigidity of the m e m b r a n e a n d the b o n e structure was sufficient for correct p l a c e m e n t o f the m e m b r a n e . Additional fixation with pillars was therefore n o t necessary. I m p l a n t p l a c e m e n t usually follows 6 - 9 m o n t h s after removal o f the m e m brane. T h e new b o n e is usually suitable for the p l a c e m e n t o f implants. The biologic reaction within this tissue to o r t h o d o n t i c t r e a t m e n t is n o t k n o w n . T h e ort h o d o n t i c t r e a t m e n t in the present case b e g a n ,8 m o n t h s after r e m o v a l of the
228
Mayer et al.
Fig. 4. Radiographs before (left side) and after (right side) treatment. Horizontal or vertical bone loss after space closure was not detectable.
membranes. O r t h o d o n t i c space closure was successful, and no a t t a c h m e n t loss was observed clinically or radiographically (Fig. 4). Localized alveolar ridge augmentation with G T R can be used as a preliminary procedure before o r t h o d o n tic treatment. F u r t h e r clinical studies are needed with long observation periods and statistical data to evaluate
whether or n o t this procedure can be used as a routine t r e a t m e n t m e t h o d .
References 1. ARORA BK, MACDONALD WORLEY C, Gvxxu RL, LASKINDM. Bone formation over partially exposed implants using guided tissue regeneration. J Oral Maxillofac Surg 1992: 50: 1060-5.
2. BECKERW, BECKERBE. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: surgical techniques and case reports. Int J Periodont Rest Dent 1990: I0:377 91. 3. BUSERD, DULA K, BELSERU, HIRT HP, BERTHOLD H. Lokaler Kieferkammaufbau mit der gesteuerten Geweberegeneration. I. Operatives Vorgehen im Oberkiefer. Int J Par Rest Zahnheilkd 1993: 13: 29-45. 4. JOVANOVIC SA, SPIEKERMANNH, RICHTER E. Bone regeneration around titanium dental implants in dehisced defect sites: a clinical study, lnt J Oral Maxillofac Implants 1992: 7:233 45. 5. LAZZARA RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodont Rest Dent 1989: 5: 333-43. 6. NYMANS, LINDHEJ, KARRINGT, RYLANDER H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982: 9: 290-6. 7. SHANAMANRH. The use of guided tissue regeneration to facilitate ideal prosthetic placement of implants. Int J Periodont Rest Dent 1992: 12: 257-65.
Address:
Dr Thomas Mayer Poliklinik fiir Zahnerhaltungskunde Im Neuenheimer Feld 400 D-69120 Heidelberg Germany