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Vertical ridge augmentation with simultaneous implant placement using β-TCP and PRP: A report of two cases
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ARTICLE IN PRESS Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2012) xxx–xxx
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Technical Note
Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases In-Seong Jeon a,b , Min-Suk Heo c , Kwang-Heung Han a,b,∗ , Jae-Hong Kim d,e a
Private Practice of S & H Dental Clinic, Seoul, Republic of Korea Department of Oral and Maxillofacial Surgery, Inje University Sanggye Paik Hospital, 620 Dong-1-ro, Nowon-gu, Seoul 139-707, Republic of Korea Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Republic of Korea d Private Practice of Seoul Top Dental Clinic, Seoul, Republic of Korea e Department of Oral and Maxillofacial Medicine, School of Dentistry, Seoul National University, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Republic of Korea b c
a r t i c l e
i n f o
Article history: Received 23 February 2012 Received in revised form 21 April 2012 Accepted 15 May 2012 Keywords: Alveolar bone loss Alveolar ridge augmentation Dental implant Guided bone regeneration Bone substitutes Platelet rich plasma
a b s t r a c t Extensive loss of alveolar bone and teeth in the posterior mandible presents a complex problem for reconstruction. Numerous augmentation techniques are currently in use to create sufficient bone volume for the reliable placement of endosseous implants in cases of severely resorbed mandibles. This clinical case report describes successful vertical ridge augmentation with the concurrent use of tricalciumphosphate (-TCP) and platelet rich plasma (PRP) at the time of implant placement. A large vertical defect was successfully reconstructed using this method without autogenous bone. Approximately 3.3 mm of vertical gain was achieved with this technique. © 2012 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1. Introduction Oral implant therapy provides satisfactory esthetic and functional outcomes for the replacement of missing teeth. To achieve such results, adequate bone volume is required to enable the placement of implants in an ideal, restorative-driven position. In many cases, implant placement is restricted by bone resorption after tooth extraction or by the positions of the mandibular canal and maxillary sinuses. Therefore, the augmentation of areas of insufficient bone volume is often indicated prior to or in conjunction with implant placement to attain predictable long-term functioning and esthetically positive treatment outcomes. These augmentation techniques have included autogenous onlay block grafts, distraction osteogenesis, and guided bone regeneration (GBR), or a combination of these methods [1–3]. Currently, autogenous bone, allogenic bone, xenogenic bone, and synthetic bone are used as bone grafting materials, and autogenous bone is widely regarded as the gold standard [4]. However, autogenous bone grafts have several disadvantages, including
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Inje University Sanggye Paik Hospital, 620 Dong-1-ro, Nowon-gu, Seoul 139-707, Republic of Korea. Tel.: +82 2 932 3618; fax: +82 2 932 3619. E-mail address: [email protected] (I.-S. Jeon).
morbidity of the donor site, limited amounts of available bone to graft and ongoing volume reduction during the healing period [5]. The following is a case report describing the reconstruction of vertically resorbed alveolar ridges using GBR with synthetic bone, PRP, non-resorbable membranes and immediate implant placement. 2. Materials and methods 2.1. PRP extraction A total of 10 cc of autologous blood was withdrawn from each patient and mixed with anticoagulant (citrate solution, 10 cc blood, and 1.5 cc of CTG). This mixture was initially centrifuged at 3000 rpm for 3 min to separate the PRP and platelet-poor plasma (PPP) portions from the red blood cells. The PRP and PPP were again centrifuged at 5000 rpm for 5 min to separate the PRP from the PPP. The extracted PRP was kept in another syringe and activated just before application with 1 cc of calcium gluconate and 1000 units of bovine thrombin to form a gel. 2.2. First stage of surgery All patients were prescribed amoxicillin with clavulanic acid, 1 g every 8 h (for 1 day preoperatively and 5 days postoperatively).
2212-5558/$ – see front matter © 2012 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ajoms.2012.05.016
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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ARTICLE IN PRESS I.-S. Jeon et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2012) xxx–xxx
2
Fig. 1. Schematic drawing of surgical procedure.
Fig. 2. A micro-textured non-resorbable membrane was prepared for easy positioning on the lingual side.
A schematic drawing is shown in Fig. 1. All of the surgical procedures were performed under local anesthesia (2% lidocaine in a 1:80,000 ratio with epinephrine). Wide exposure of the edentulous mandibular ridge was achieved with a crestal incision from the distal part of the most posterior tooth to ascending ramus and with a vertical release incision along the distobuccal gingiva of the most posterior tooth. After initial drilling with a 2.0 mm diameter drill, a panoramic radiograph was obtained to measure the distance between the inferior alveolar nerve and the guiding pin and to confirm 1–2 mm of safe distance. The implant fixtures were installed after the final drilling. The cortical bone surrounding the implant fixtures was decorticated with a lance drill to provide sufficient blood supply. A mixture of PRP and beta-tricalcium phosphate (-TCP) was then grafted over the fixtures with approximately 1 mm of overgrafting to compensate for material resorption (Figs. 2 and 3). A non-resorbable barrier membrane (Cytoplast TXT-200, Osteogenics Biomedical, USA) was applied and fixed using 4-0 nylon (Happylon, Purgo Tissue Bank) horizontal mattress suture for the stabilization of the bone substitute and membrane (Fig. 4). Vertical mattress and single interrupted sutures were both utilized for tight fixation. Fig. 5 shows the length of the exposed fixture before grafting.
Fig. 3. Denuded fixtures were surrounded by -TCP mixed with PRP.
implant fixture and the amount of thread exposure were evaluated (Fig. 6). Healing caps were installed onto the implant fixtures, and the sites were closed using simple interrupted sutures. 3. Case reports 3.1. Case 1 A 60-year-old woman visited our clinic with long-term edentulism of her lower left posterior teeth. No significant medical
2.3. Second stage of surgery After 6 months of healing, the second stage of surgery was performed under local anesthesia. A crestal incision and mucoperiosteal flap reflection were performed for the removal of the barrier membrane. The newly formed bone surrounding the
Fig. 4. Barrier membrane covering the fixtures and bone substitutes stabilized with horizontal mattress sutures.
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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Fig. 5. Schematic drawing of pre-operative and post-operative bone level change (related to Tables 1 and 2). Parameters – L: exposed length of the implant before transplantation during the first surgery: height of the augmented bone. L1: mesial part of the first implant. L2: central part between the first and the second implants. L3: distal part of the second implant. l: resorbed length of the bone material at the time of the second surgery. L − l: final height of augmented bone.
3
Fig. 7. Case 1: preoperative panoramic view showing inadequate vertical bone height.
history was discovered. Severe bone atrophy was observed, and the short distance from the alveolar crest to the inferior alveolar canal made implant placement difficult. Vertical ridge augmentation was performed immediately after supra-implantation with a mixture of PRP and -TCP (Cerasorb). The interocclusal distance was sufficiently long to perform vertical ridge augmentation. Bonelevel internal-type implants (GS lll, 4.5 mm × 7 mm, Osstem, Korea) with RBM surfaces were installed. After 6 months, the second stage of surgery and prosthetic procedures were performed (Figs. 7–9). No clinically significant symptoms were observed after loading although a small amount of bone loss was observed radiographically. 3.2. Case 2 A 68-year-old woman visited our clinic with long-term edentulism of her lower right posterior teeth. She had no significant medical history. The radiological examination revealed severe alveolar bone loss in the lower right posterior area. Sufficient length for implant installation was impossible because of the position of the inferior alveolar nerve. Reconstruction of the alveolar ridge with vertical augmentation techniques was planned. All of the procedures were performed using the same methods as in Case 1. Bone level internal type implants (GS lll, 4.0 mm × 8.5 mm, Osstem, Korea) with RBM surfaces were installed (Figs. 10–12).
Fig. 6. After the 6-month healing period, a small incision was made, and the barrier membrane was removed.
Fig. 8. Case 1: postoperative panoramic view showing implant installation with vertical ridge augmentation.
4. Discussion Dental implant restoration is now possible in once-inoperable areas of edentulism because of great progress in dental implant surgery techniques. However, certain limitations exist, such as adjacent anatomical structures especially in the posterior mandible. To overcome anatomical limitations in these areas, many surgical techniques have been introduced (e.g., transposition of the
Fig. 9. Case 1: prosthodontic rehabilitation 6 months after surgery.
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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Fig. 10. Case 2: preoperative panoramic view showing inadequate vertical bone height.
Fig. 11. Case 2: postoperative panoramic view showing implant installation with vertical ridge augmentation.
inferior alveolar nerve, distraction osteogenesis, autogenous block bone graft, and GBR technique with various barrier membranes) [1–3,5–8]. One technique uses autogenous block bone, which has the ability to resist external forces. Many trials have attempted to prevent the donor site morbidity that occurs with autogenous block bone harvesting. Some authors have reported that a xenogenic bone block could be an effective bone scaffold for vertical bone augmentation [9]. Other authors have reconstructed severely resorbed anterior and posterior alveolar ridges with cancellous allograft blocks as an autogenous bone substitute [10].
Fig. 12. Case 2: periapical view showing stable marginal bone around the implant fixture 6 months after surgery.
Another trial utilized reconstruction with guided bone regeneration (GBR). Many studies have suggested that extra skeletal bone formation is possible in regions without surrounding bone [11–13]. Some authors have also reported the production of bone tissue using the lateral surface of the murine mandibular ramus (i.e., out of the skeletal envelope), with a rigid and hemispherical Teflon capsule. The newly created bone tissue was reported to be stable when used with implant placement [14]. Reconstruction of the severely resorbed alveolar bone ridge is considered to be similar to extra-skeletal bone formation. A rigid barrier is therefore necessary to prevent soft tissue ingrowth and to resist external pressure. Some authors have introduced the screw “tentpole” graft technique as a vertical augmentation method. For the reconstruction of vertical alveolar ridge defects, screws were used to tent out the soft tissue matrix and the inner space was then filled with mineralized human allograft material. At surgical re-entry after four and a half months, the entire graft site was reported to consist of viable bone [15]. Similarly, Canullo and Malagnino used implant fixtures rather than titanium screws as tent-poles before filling the space with bovine bone matrix [16]. In our own experience, the implant fixture itself performed the partial role of a rigid barrier while protecting against vertically harmful forces. -TCP could potentially support the membrane as well. Chappard et al. performed sinus lift augmentation with -TCP and evaluated the bone formation with micro-CT and histological analyses; they reported that -TCP seemed acceptable as a sinus grafting material because of its osteoconductive nature. Furthermore, the material was easily degraded by macrophages without inducing any inflammation. Finally, the macroporosity of the granules ensured sufficient space for vascular sprouting and osteoprogenitor cell invasion [17]. Various studies have shown that alloplastic materials such as TCP can act as scaffolds in bone formation; these materials are similar to xenogenic materials in GBR [18,19]. TCP, which has macro- and micro-porosity, accelerates this type of bone formation without an inflammatory response. TCP is also easily degraded naturally without disturbing bone formation, although xenogenic bone is barely resorbed and occupies spaces for uncharacteristically long periods of time. Thus, bone substitutes should ideally perform the role of a scaffold and should also be resorbed when osteoblasts begin to produce new bone tissue. The properties of TCP provide the closest match for such requirements. However, TCP material has some disadvantages such as a lower rate of bony substitution relative to autogenous bone as well as poor stability. Therefore, in this study, TCP was mixed with PRP, which had the beneficial effect of increasing the viscosity of the graft material and accelerating bone healing. PRP, which consists of a volume of plasma with a high concentration of platelets, has been suggested to increase the rate of bone deposition and bone volume in combination with bone grafts when used during augmentation procedures. It has also been demonstrated that the application of PRP in bone grafting might be beneficial for bone healing. The positive effect of PRP on bone healing has been attributed to the angiogenic, proliferative, and differentiating effects of transforming growth factor- and platelet-derived growth factor, which are both present in high concentrations in PRP [20–22]. Therefore, the combination of PRP with -TCP may result in an increased rate of bone formation in ridge augmentation procedures. The combination of a rigid barrier membrane and bone substitutes is intended to create an ideal environment for bone formation and alveolar ridge reconstruction. In this report, we used TCP and PRP as a scaffold and we used a micro-textured non-resorbable membrane (Cytoplast TXT-200, Osteogenics Biomedical, USA) as
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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Table 1 Case 1: amount of augmentation and postoperative resorption (related to Fig. 5). Case 1
Mesial (L1/l1)
Central (L2/l2)
Distal (L3/l3)
L (mm) l (mm) L−l
3.5 0.2 3.3
4.3 0.2 4.1
3.3 0 3.3
5
Competing interests None declared. Ethical approval Not required.
Table 2 Case 2: amount of augmentation and postoperative resorption (related to Fig. 5). Case 2
Mesial (L1/l1)
Central (L2/l2)
Distal (L3/l3)
L (mm) l (mm) L−l
3.1 0 3.1
3.6 0 3.6
3.0 0 3.0
a barrier. Overall, we obtained clinically satisfactory results. The membrane was somewhat unfavorable for maintaining the space, especially when compared with a titanium mesh. However, the shortcomings of this flexible membrane were compensated for by the supporting effect of the implant fixture itself. Moreover, this membrane could be easily removed using only a single crestal incision without a vertical incision. Therefore, this membrane prevented the bone resorption associated with flap reflection during the second surgery, which often results in increased bone resorption, especially when extensive flap reflection is used to remove the titanium mesh. Cases 1 and 2 showed almost no bone resorption (Tables 1 and 2). We used bone level type implant fixtures that lacked collar parts. This type of implant was thought to facilitate suturing and reduce tissue tension, thereby decreasing the risk of membrane exposure. In our study, no membrane exposure was observed, although we were unable to obtain definitive conclusions given our small sample size. If membrane exposure does occur, effective plaque control with daily dressing of the exposure area can be helpful in preventing graft material loss. We focused our study on the management of insufficient bone volumes between the alveolar crest and the mandibular canal. However, interocclusal clearance is another important factor in the prosthodontic rehabilitation of edentulous areas. Insufficient interocclusal clearance is an indication for the repositioning of opposing teeth to increase the vertical space. Crown reduction with endodontic therapy, orthodontic intrusion or surgical correction (e.g., posterior segmental osteotomy) may also be considered [23,24]. The repositioning of the inferior alveolar nerve is an option, although this method is risky because of the possibility of nerve damage [6]. We did not use temporary prostheses for our surgical areas because the pressure from temporary dentures could have inhibited the maturation of the grafted bone. Because vertically augmented bone is not supported by the surrounding alveolar bone, pressure should be avoided during the healing period. We therefore used resin wire splinting of the opposing dentition to prevent elongation of the opposing teeth. Because we reported only two cases here, it is difficult to draw definitive conclusions regarding the long-term effects and prognoses of this method. However, this surgical technique is relatively easy to perform and does not require large volumes of autogenous bone such as block bone. Additional long-term studies are warranted.
Funding None.
References [1] Keller EE, Tolman DE, Eckert S. Surgical-prosthodontic reconstruction of advanced maxillary bone compromise with autogenousonaly block grafts and osseointegrated endosseous implants: a 12 year study of 32 consecutive patients. International Journal of Oral and Maxillofacial Implants 1999;12:197. [2] Uckan S, Veziroglu F, Dayangac E. Alveolar distraction osteogenesis versus autogenous onlay bone grafting for alveolar ridge augmentation: technique, complications, and implant survival rates. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 2008;106:511–5. [3] Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clinical Oral Implants Research 1990;1:22–32. [4] Marx RE. Clinical application of bone biology to mandibular and maxillary reconstruction. Clinics in Plastic Surgery 1994;21:377–92. [5] Simion M, Jovanovic SA, Tinti C, Benfenai SP. Long-term evaluation of osseointegrated implants inserted at the time or after vertical ridge augmentation. A retrospective study on 123 implants with 1–5 year follow-up. Clinical Oral Implants Research 2001;12:35–45. [6] Smiler DG. Repositioning the inferior alveolar nerve for placement of endosseous implants: technical note. International Journal of Oral and Maxillofacial Implants 1993;8:145–50. [7] Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. International Journal of Oral and Maxillofacial Implants 1997;12:767. [8] Rasmusson L, Meredith N, Kahnberg KE, Sennerby L. Effects of barrier membranes on bone resorption and implant stability in onlay bone grafts. An experimental study. Clinical Oral Implants Research 1999;10:267. [9] Daniel R, Frank S, Monika H, Daniel F, Robert A, Martin S, et al. Vertical ridge augmentation using xeogenous bone blocks: a histomorphometric study in dogs. International Journal of Oral and Maxillofacial Implants 2009;24:243–50. [10] Chaushu G, Mardinger O, Calderon S, Moses O, Nissan J. The use of cancellous block allograft for sinus floor augmentation with simultaneous implant placement in the posterior atrophic maxilla. Journal of Periodontology 2009;80:422–8. [11] Linde A, Thoren C, Dahlin C, Sandberg E. Creation of new bone by an osteopromotive membrane technique: an experimental study in rats. Journal of Oral and Maxillofacial Surgery 1993;51:892–7. [12] Lundgren D, Lundgren AK, Sennerby L, Nyman S. Augmentation of intramembraneous bone beyond the skeletal envelope using an occlusive titanium barrier. An experimental study in the rabbit. Clinical Oral Implants Research 1995;6:67–72. [13] Stavropoulos A, Kostopoulos L, Mardas N, Nyengaard JR, Karring T. Gentamicin used as an adjunct to GTR. Journal of Clinical Periodontology 2003;30: 455–62. [14] Stavropoulos A, Nyengaard JR, Kostopoulos L, Karring T. Implant placement in bone formed beyond the skeletal envelope b means of guided tissue regeneration: an experimental study in the rat. Journal of Clinical Periodontology 2005;32:1108–15. [15] Le B, Rohrer MD, Prasad HS. Screw “tent-pole” grafting technique for reconstruction of large vertical alveolar ridge defects using human mineralized allograft for implant site preparation. Journal of Oral and Maxillofacial Surgery 2010;68:428–35. [16] Canullo L, Malagnino VA. Vertical ridge augmentation around implants by e-PTFE titanium-reinforced membrane and bovine bone matrix: a 24- to 54-month study of 10 consecutive cases. International Journal of Oral and Maxillofacial Implants 2008;23:858–66. [17] Chappard D, Guillaume B, Mallet R, Pascaretti-Grizon F, Baslé MF, Libouban H. Sinus lift augmentation and beta-TCP: a microCT and histologic analysis on human bone biopsies. Micron 2010;41:321–6. [18] Benic´ GI, Jung RE, Siegenthaler DW, Hämmerle CH. Clinical and radiographic comparison of implants in regenerated or native bone: 5-year results. Clinical Oral Implants Research 2009;20:507–13. [19] Kohal RJ, Mellas P, Hürzeler MB, Trejo PM, Morrison E, Caffesse RG. The effects of guided bone regeneration and grafting on implants placed into immediate extraction sockets. An experimental study in dogs. Journal of Periodontology 1998;69:927–37. [20] Nikolidakis D, Meijer GJ, Jansen JA. Sinus floor elevation using platelet-rich plasma and beta-tricalcium phosphate: case report and histological evaluation. Dentistry Today 2008;27, 66, 68, 70 [quiz 71]. [21] Scanchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. International Journal of Oral and Maxillofacial Implants 2003;18:93–103.
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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[22] Anitua E. Plasma rich in growth factors: preliminary results of use in the preparation of future sites for implants. International Journal of Oral and Maxillofacial Implants 1999;14:529–35. [23] Ohura R, Kuroda S, Takahashi T, Tomita Y, Tanaka E. Efficient usage of implant anchorage to treat overerupted maxillary first molar and mesially inclined
mandibular molars. American Journal of Orthodontics and Dentofacial Orthopedics 2011;139:113–22. [24] Basa S, Varol A, Sener ID, Sertgoz A. Posterior maxillary segmental osteotomy for restoring the mandible with dental implants: a clinical report. Journal of Prosthetic Dentistry 2008;99:340–3.
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
ARTICLE IN PRESS Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2012) xxx–xxx
Contents lists available at SciVerse ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Technical Note
Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases In-Seong Jeon a,b , Min-Suk Heo c , Kwang-Heung Han a,b,∗ , Jae-Hong Kim d,e a
Private Practice of S & H Dental Clinic, Seoul, Republic of Korea Department of Oral and Maxillofacial Surgery, Inje University Sanggye Paik Hospital, 620 Dong-1-ro, Nowon-gu, Seoul 139-707, Republic of Korea Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Republic of Korea d Private Practice of Seoul Top Dental Clinic, Seoul, Republic of Korea e Department of Oral and Maxillofacial Medicine, School of Dentistry, Seoul National University, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Republic of Korea b c
a r t i c l e
i n f o
Article history: Received 23 February 2012 Received in revised form 21 April 2012 Accepted 15 May 2012 Keywords: Alveolar bone loss Alveolar ridge augmentation Dental implant Guided bone regeneration Bone substitutes Platelet rich plasma
a b s t r a c t Extensive loss of alveolar bone and teeth in the posterior mandible presents a complex problem for reconstruction. Numerous augmentation techniques are currently in use to create sufficient bone volume for the reliable placement of endosseous implants in cases of severely resorbed mandibles. This clinical case report describes successful vertical ridge augmentation with the concurrent use of tricalciumphosphate (-TCP) and platelet rich plasma (PRP) at the time of implant placement. A large vertical defect was successfully reconstructed using this method without autogenous bone. Approximately 3.3 mm of vertical gain was achieved with this technique. © 2012 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1. Introduction Oral implant therapy provides satisfactory esthetic and functional outcomes for the replacement of missing teeth. To achieve such results, adequate bone volume is required to enable the placement of implants in an ideal, restorative-driven position. In many cases, implant placement is restricted by bone resorption after tooth extraction or by the positions of the mandibular canal and maxillary sinuses. Therefore, the augmentation of areas of insufficient bone volume is often indicated prior to or in conjunction with implant placement to attain predictable long-term functioning and esthetically positive treatment outcomes. These augmentation techniques have included autogenous onlay block grafts, distraction osteogenesis, and guided bone regeneration (GBR), or a combination of these methods [1–3]. Currently, autogenous bone, allogenic bone, xenogenic bone, and synthetic bone are used as bone grafting materials, and autogenous bone is widely regarded as the gold standard [4]. However, autogenous bone grafts have several disadvantages, including
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Inje University Sanggye Paik Hospital, 620 Dong-1-ro, Nowon-gu, Seoul 139-707, Republic of Korea. Tel.: +82 2 932 3618; fax: +82 2 932 3619. E-mail address: [email protected] (I.-S. Jeon).
morbidity of the donor site, limited amounts of available bone to graft and ongoing volume reduction during the healing period [5]. The following is a case report describing the reconstruction of vertically resorbed alveolar ridges using GBR with synthetic bone, PRP, non-resorbable membranes and immediate implant placement. 2. Materials and methods 2.1. PRP extraction A total of 10 cc of autologous blood was withdrawn from each patient and mixed with anticoagulant (citrate solution, 10 cc blood, and 1.5 cc of CTG). This mixture was initially centrifuged at 3000 rpm for 3 min to separate the PRP and platelet-poor plasma (PPP) portions from the red blood cells. The PRP and PPP were again centrifuged at 5000 rpm for 5 min to separate the PRP from the PPP. The extracted PRP was kept in another syringe and activated just before application with 1 cc of calcium gluconate and 1000 units of bovine thrombin to form a gel. 2.2. First stage of surgery All patients were prescribed amoxicillin with clavulanic acid, 1 g every 8 h (for 1 day preoperatively and 5 days postoperatively).
2212-5558/$ – see front matter © 2012 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ajoms.2012.05.016
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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ARTICLE IN PRESS I.-S. Jeon et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2012) xxx–xxx
2
Fig. 1. Schematic drawing of surgical procedure.
Fig. 2. A micro-textured non-resorbable membrane was prepared for easy positioning on the lingual side.
A schematic drawing is shown in Fig. 1. All of the surgical procedures were performed under local anesthesia (2% lidocaine in a 1:80,000 ratio with epinephrine). Wide exposure of the edentulous mandibular ridge was achieved with a crestal incision from the distal part of the most posterior tooth to ascending ramus and with a vertical release incision along the distobuccal gingiva of the most posterior tooth. After initial drilling with a 2.0 mm diameter drill, a panoramic radiograph was obtained to measure the distance between the inferior alveolar nerve and the guiding pin and to confirm 1–2 mm of safe distance. The implant fixtures were installed after the final drilling. The cortical bone surrounding the implant fixtures was decorticated with a lance drill to provide sufficient blood supply. A mixture of PRP and beta-tricalcium phosphate (-TCP) was then grafted over the fixtures with approximately 1 mm of overgrafting to compensate for material resorption (Figs. 2 and 3). A non-resorbable barrier membrane (Cytoplast TXT-200, Osteogenics Biomedical, USA) was applied and fixed using 4-0 nylon (Happylon, Purgo Tissue Bank) horizontal mattress suture for the stabilization of the bone substitute and membrane (Fig. 4). Vertical mattress and single interrupted sutures were both utilized for tight fixation. Fig. 5 shows the length of the exposed fixture before grafting.
Fig. 3. Denuded fixtures were surrounded by -TCP mixed with PRP.
implant fixture and the amount of thread exposure were evaluated (Fig. 6). Healing caps were installed onto the implant fixtures, and the sites were closed using simple interrupted sutures. 3. Case reports 3.1. Case 1 A 60-year-old woman visited our clinic with long-term edentulism of her lower left posterior teeth. No significant medical
2.3. Second stage of surgery After 6 months of healing, the second stage of surgery was performed under local anesthesia. A crestal incision and mucoperiosteal flap reflection were performed for the removal of the barrier membrane. The newly formed bone surrounding the
Fig. 4. Barrier membrane covering the fixtures and bone substitutes stabilized with horizontal mattress sutures.
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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ARTICLE IN PRESS I.-S. Jeon et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2012) xxx–xxx
Fig. 5. Schematic drawing of pre-operative and post-operative bone level change (related to Tables 1 and 2). Parameters – L: exposed length of the implant before transplantation during the first surgery: height of the augmented bone. L1: mesial part of the first implant. L2: central part between the first and the second implants. L3: distal part of the second implant. l: resorbed length of the bone material at the time of the second surgery. L − l: final height of augmented bone.
3
Fig. 7. Case 1: preoperative panoramic view showing inadequate vertical bone height.
history was discovered. Severe bone atrophy was observed, and the short distance from the alveolar crest to the inferior alveolar canal made implant placement difficult. Vertical ridge augmentation was performed immediately after supra-implantation with a mixture of PRP and -TCP (Cerasorb). The interocclusal distance was sufficiently long to perform vertical ridge augmentation. Bonelevel internal-type implants (GS lll, 4.5 mm × 7 mm, Osstem, Korea) with RBM surfaces were installed. After 6 months, the second stage of surgery and prosthetic procedures were performed (Figs. 7–9). No clinically significant symptoms were observed after loading although a small amount of bone loss was observed radiographically. 3.2. Case 2 A 68-year-old woman visited our clinic with long-term edentulism of her lower right posterior teeth. She had no significant medical history. The radiological examination revealed severe alveolar bone loss in the lower right posterior area. Sufficient length for implant installation was impossible because of the position of the inferior alveolar nerve. Reconstruction of the alveolar ridge with vertical augmentation techniques was planned. All of the procedures were performed using the same methods as in Case 1. Bone level internal type implants (GS lll, 4.0 mm × 8.5 mm, Osstem, Korea) with RBM surfaces were installed (Figs. 10–12).
Fig. 6. After the 6-month healing period, a small incision was made, and the barrier membrane was removed.
Fig. 8. Case 1: postoperative panoramic view showing implant installation with vertical ridge augmentation.
4. Discussion Dental implant restoration is now possible in once-inoperable areas of edentulism because of great progress in dental implant surgery techniques. However, certain limitations exist, such as adjacent anatomical structures especially in the posterior mandible. To overcome anatomical limitations in these areas, many surgical techniques have been introduced (e.g., transposition of the
Fig. 9. Case 1: prosthodontic rehabilitation 6 months after surgery.
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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Fig. 10. Case 2: preoperative panoramic view showing inadequate vertical bone height.
Fig. 11. Case 2: postoperative panoramic view showing implant installation with vertical ridge augmentation.
inferior alveolar nerve, distraction osteogenesis, autogenous block bone graft, and GBR technique with various barrier membranes) [1–3,5–8]. One technique uses autogenous block bone, which has the ability to resist external forces. Many trials have attempted to prevent the donor site morbidity that occurs with autogenous block bone harvesting. Some authors have reported that a xenogenic bone block could be an effective bone scaffold for vertical bone augmentation [9]. Other authors have reconstructed severely resorbed anterior and posterior alveolar ridges with cancellous allograft blocks as an autogenous bone substitute [10].
Fig. 12. Case 2: periapical view showing stable marginal bone around the implant fixture 6 months after surgery.
Another trial utilized reconstruction with guided bone regeneration (GBR). Many studies have suggested that extra skeletal bone formation is possible in regions without surrounding bone [11–13]. Some authors have also reported the production of bone tissue using the lateral surface of the murine mandibular ramus (i.e., out of the skeletal envelope), with a rigid and hemispherical Teflon capsule. The newly created bone tissue was reported to be stable when used with implant placement [14]. Reconstruction of the severely resorbed alveolar bone ridge is considered to be similar to extra-skeletal bone formation. A rigid barrier is therefore necessary to prevent soft tissue ingrowth and to resist external pressure. Some authors have introduced the screw “tentpole” graft technique as a vertical augmentation method. For the reconstruction of vertical alveolar ridge defects, screws were used to tent out the soft tissue matrix and the inner space was then filled with mineralized human allograft material. At surgical re-entry after four and a half months, the entire graft site was reported to consist of viable bone [15]. Similarly, Canullo and Malagnino used implant fixtures rather than titanium screws as tent-poles before filling the space with bovine bone matrix [16]. In our own experience, the implant fixture itself performed the partial role of a rigid barrier while protecting against vertically harmful forces. -TCP could potentially support the membrane as well. Chappard et al. performed sinus lift augmentation with -TCP and evaluated the bone formation with micro-CT and histological analyses; they reported that -TCP seemed acceptable as a sinus grafting material because of its osteoconductive nature. Furthermore, the material was easily degraded by macrophages without inducing any inflammation. Finally, the macroporosity of the granules ensured sufficient space for vascular sprouting and osteoprogenitor cell invasion [17]. Various studies have shown that alloplastic materials such as TCP can act as scaffolds in bone formation; these materials are similar to xenogenic materials in GBR [18,19]. TCP, which has macro- and micro-porosity, accelerates this type of bone formation without an inflammatory response. TCP is also easily degraded naturally without disturbing bone formation, although xenogenic bone is barely resorbed and occupies spaces for uncharacteristically long periods of time. Thus, bone substitutes should ideally perform the role of a scaffold and should also be resorbed when osteoblasts begin to produce new bone tissue. The properties of TCP provide the closest match for such requirements. However, TCP material has some disadvantages such as a lower rate of bony substitution relative to autogenous bone as well as poor stability. Therefore, in this study, TCP was mixed with PRP, which had the beneficial effect of increasing the viscosity of the graft material and accelerating bone healing. PRP, which consists of a volume of plasma with a high concentration of platelets, has been suggested to increase the rate of bone deposition and bone volume in combination with bone grafts when used during augmentation procedures. It has also been demonstrated that the application of PRP in bone grafting might be beneficial for bone healing. The positive effect of PRP on bone healing has been attributed to the angiogenic, proliferative, and differentiating effects of transforming growth factor- and platelet-derived growth factor, which are both present in high concentrations in PRP [20–22]. Therefore, the combination of PRP with -TCP may result in an increased rate of bone formation in ridge augmentation procedures. The combination of a rigid barrier membrane and bone substitutes is intended to create an ideal environment for bone formation and alveolar ridge reconstruction. In this report, we used TCP and PRP as a scaffold and we used a micro-textured non-resorbable membrane (Cytoplast TXT-200, Osteogenics Biomedical, USA) as
Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016
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Table 1 Case 1: amount of augmentation and postoperative resorption (related to Fig. 5). Case 1
Mesial (L1/l1)
Central (L2/l2)
Distal (L3/l3)
L (mm) l (mm) L−l
3.5 0.2 3.3
4.3 0.2 4.1
3.3 0 3.3
5
Competing interests None declared. Ethical approval Not required.
Table 2 Case 2: amount of augmentation and postoperative resorption (related to Fig. 5). Case 2
Mesial (L1/l1)
Central (L2/l2)
Distal (L3/l3)
L (mm) l (mm) L−l
3.1 0 3.1
3.6 0 3.6
3.0 0 3.0
a barrier. Overall, we obtained clinically satisfactory results. The membrane was somewhat unfavorable for maintaining the space, especially when compared with a titanium mesh. However, the shortcomings of this flexible membrane were compensated for by the supporting effect of the implant fixture itself. Moreover, this membrane could be easily removed using only a single crestal incision without a vertical incision. Therefore, this membrane prevented the bone resorption associated with flap reflection during the second surgery, which often results in increased bone resorption, especially when extensive flap reflection is used to remove the titanium mesh. Cases 1 and 2 showed almost no bone resorption (Tables 1 and 2). We used bone level type implant fixtures that lacked collar parts. This type of implant was thought to facilitate suturing and reduce tissue tension, thereby decreasing the risk of membrane exposure. In our study, no membrane exposure was observed, although we were unable to obtain definitive conclusions given our small sample size. If membrane exposure does occur, effective plaque control with daily dressing of the exposure area can be helpful in preventing graft material loss. We focused our study on the management of insufficient bone volumes between the alveolar crest and the mandibular canal. However, interocclusal clearance is another important factor in the prosthodontic rehabilitation of edentulous areas. Insufficient interocclusal clearance is an indication for the repositioning of opposing teeth to increase the vertical space. Crown reduction with endodontic therapy, orthodontic intrusion or surgical correction (e.g., posterior segmental osteotomy) may also be considered [23,24]. The repositioning of the inferior alveolar nerve is an option, although this method is risky because of the possibility of nerve damage [6]. We did not use temporary prostheses for our surgical areas because the pressure from temporary dentures could have inhibited the maturation of the grafted bone. Because vertically augmented bone is not supported by the surrounding alveolar bone, pressure should be avoided during the healing period. We therefore used resin wire splinting of the opposing dentition to prevent elongation of the opposing teeth. Because we reported only two cases here, it is difficult to draw definitive conclusions regarding the long-term effects and prognoses of this method. However, this surgical technique is relatively easy to perform and does not require large volumes of autogenous bone such as block bone. Additional long-term studies are warranted.
Funding None.
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Please cite this article in press as: Jeon I-S, et al. Vertical ridge augmentation with simultaneous implant placement using -TCP and PRP: A report of two cases. J Oral Maxillofac Surg Med Pathol (2012), http://dx.doi.org/10.1016/j.ajoms.2012.05.016