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Ridge augmentation with titanium mesh: A case report
J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
Available online at
ScienceDirect www.sciencedirect.com
Case Report
Ridge augmentation with titanium mesh: A case report H. Jegham *, R. Masmoudi, H. Ouertani, I. Blouza, S. Turki, M.B. Khattech Military Hospital, No 8, Univers street, Tunis, Tunisia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 October 2016 Accepted 16 March 2017 Available online 28 March 2017
Insufficient bone volume for dental implant placement in the maxillary anterior segment is a constant challenge in oral surgery. Several techniques have been suggested to reconstruct deficient alveolar ridges and to facilitate dental implant placement. These techniques include bone splitting osteotomy, distraction osteogenesis, inlay and onlay bone grafting. Guided bone regeneration (GBR) is also a promising alternative that increases the bone volume by the use of a subperiosteal barrier. Aim: The aim of this case was to demonstrate that the use of rigid titanium occlusive barrier is a reliable alternative to perform a lateral alveolar bone augmentation and treat localized ridge deformities before reaching an ideal implant placement. Observation: A 25-year-old healthy male was referred for implant placement in the maxillary central incisor. The alveolar bone width at the implant site 21 was less than 5 mm. Hard tissue augmentation was accomplished using guided bone regeneration. A rigid titanium occlusive barrier was customized to desired shape of future alveolar ridge then secured with tent and fixing screws. Autogenous bone graft harvested with an auto-chip-maker adjacent to the surgical site were mixed with a xenograft and putted under the barrier. The wound was closed using a vestibular mucoperiosteal flap. At 4 months, the rigid barrier was removed, and a 7 mm crestal width transversal bone was observed. At the same time, a fixture (4 10 mm) was placed. A definitive ceramometal crown was completed after full osseointegration with periodical clinical maintenance. The exposure of the titanium mesh occurred in this case and was visible with a circular flap dehiscence at 1-month follow-up visit. This exposure did not affect the successful regenerative outcomes. After removal of the titanium mesh from the grafted defects, the space beneath the membrane enclosure was seen to be almost completely filled with new hard tissue covered by a thin layer of soft tissue. The postoperative follow-ups revealed that the implant was stable with excellent osseointegration and the buccal depression of the surgical area was reconstructed. Conclusion: The use of rigid titanium occlusive screwed barrier with autogenous and bovine bone graft might be a reliable technique for alveolar ridge reconstruction. This approach achieve excellent final esthetic outcome of the implant-supported restoration. Published by Elsevier Masson SAS.
1. Introduction Insufficient bone volume for dental implant placement in the maxillary anterior segment leads to functional and esthetic problems and can be difficult to solve. Several techniques have been suggested to reconstruct deficient alveolar ridges and to facilitate dental implant placement. These techniques include bone splitting osteotomy, distraction osteogenesis, inlay and onlay bone grafting [1]. Guided bone regeneration (GBR) is also a promising alternative that increases the bone volume by the use of a subperiosteal barrier [2].
* Corresponding author. E-mail address: [email protected] (H. Jegham). http://dx.doi.org/10.1016/j.jormas.2017.03.001 2468-7855/Published by Elsevier Masson SAS.
Expanded polytetrafluoroethylen (ePTFE) was the first nonresorbable membrane proposed to allow spontaneous bone growth after the formation of a coagulum below the barrier and then permitting guided bone regeneration [3]. Besides, PTFE membrane, titanium mesh is another nonresorbable material used in multiple medical applications and, more recently, for dental bone repair. The use of titanium mesh was first introduced by Boyne in 1969, for the reconstruction of large osseous defects [4]. The stiffness of this membrane makes it easy to customize and to shape. Hence, the creation and the maintenance of a space for graft placement could prevent the collapse of the biomaterial and provide GBR. The aim of this case was to demonstrate that the use of rigid titanium occlusive barrier is a reliable alternative to perform a
182
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
lateral alveolar bone augmentation and treat localized ridge deformities before reaching an ideal implant placement.
2. Observation A 25-year-old healthy man was referred for implant placement in the maxillary central incisor. The patient reported a history of trauma and inadequate endodontic treatments leading to the loss of the tooth 21 (Figs. 1 and 2). The cone-beam reveals at the implant site horizontal bone resorption, the width of the alveolar ridge was less than 5 mm (class H-m according to Wang HVC classification [2002]) [5] (Fig. 3). Therefore, we decided to perform lateral bone augmentation before implant placement by the use of a titanium mesh for GBR. After reflection of a full thickness flap, a rigid titanium occlusive barrier (CTi-mem Type B, Neobiotech, Seoul, Korea) was trimmed and contoured to desired shape of future alveolar ridge, then secured with tent screws. Autogenous bone graft harvested with an auto-chip-maker (ACM, Neobiotech, Seoul, Korea) adjacent to the surgical site were mixed with a xenograft (Cerabone1, Biomaterials GmbH, Germany) and placed under the barrier. Next, fixing screw was used to secure the mesh and the bone graft material. The wound was closed using a buccal mucoperiosteal flap coronally repositioned (Figs. 4–9). The postoperative care includes use of antibiotic (amoxicillin 500 mg orally 3 times daily for 7 days) and an analgesic. Patient was instructed to rinse with chlorhexidine 0, 12% twice daily for 2 weeks. Sutures were removed 10 days after surgery. At 4 months of healing, the augmented site was reopened using a crestal incision. Once it is fully exposed, the rigid barrier was removed, and a 7 mm crestal width transversal bone was observed. At the same time, a fixture (4 10 mm, NeoCMI implant, Neobiotech, Seoul, South Korea) was placed. Six months later, we undertake the second time surgery and an adequate healing
Fig. 1. Preoperative view of the site.
Fig. 2. Occlusal view with vestibular tissue loss.
Fig. 3. Bone defect on site 11 observed on the cone beam.
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
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Fig. 4. Full thickness flap elevation exposing a large horizontal defect.
abutment was screwed. Then, a definitive ceramometal crown was completed with periodical clinical maintenance. During the healing phase, a small circular flap dehiscence and exposure of the titanium mesh occurred and were visible at onemonth follow-up visit. In this case, there were no clinical signs of inflammation or infection. This exposure did not affect the successful regenerative outcomes. Patient was maintained on chlorhexidine gel until the time of mesh removal. He came in for weekly appointments for bacterial plaque control and to verify the status of the clinical healing (Fig. 10).
Fig. 7. The titanium mesh is trimmed and contoured to the desired shape of the future alveolar ridge.
Fig. 5. Decortication of the buccal plate to expose bone marrow.
Fig. 6. A tenting screw is putted on the top of the ridge.
Figs. 8 and 9. The space under the mesh is filled with a xenograft mixed with autogenous bone graft and then the mesh is fixed with a fixing screw.
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H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
Fig. 10. One month later, there is a circular shape exposure of the titanium mesh and the tenting screw without any signs of inflammation.
Fig. 13. A 4 mm diameter fixture is putted after ridge reconstruction.
3. Discussion At the reentry procedure, the titanium mesh appeared to be surrounded by tissues with little signs of clinical inflammation. The newly formed tissue under the mesh allows the placement of a 4mm 10 mm fixture. Implant site preparation revealed a regenerated hard tissue clinically consistent with alveolar bone. During implant osteotomy preparation, significant resistance was noted, the implant was then inserted with a primary stability of 40 N/cm (Figs. 11–13). The postoperative follow-up revealed that the implant was stable with excellent osseointegration and the buccal depression of the surgical area was reconstructed (Figs. 14–18).
Figs. 11 and 12. At reentry after six months, we remove the titanium mesh and the tenting screw. A high quantity of a newly regenerated tissue is observed.
Having an adequate bone volume is certainly an important prerequisite for a long-term implant success. Among the various techniques developed to increase bone volume, GBR and the use of bone grafting materials or combination of these two methods are reported as providing the best and the most predictable results [6]. Many factors contribute to successful GBR outcomes. Barriers membranes must fulfill a certain design criteria as described by Scantlebury such as biocompatibility, space making, cell occlusiveness, tissue integration and clinical manageability. Barriers membranes are grouped as resorbable and non-resorbable membranes [3]. Titanium mesh is non-resorbable membrane that has been extensively used in surgical dental application because of its
Figs. 14 and 15. Six months later, we start the second surgical time and a large diameter-healing abutment is connected.
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
Figs. 16 and 17. The definitive prostheses is cemented one month later with a good esthetic result.
Fig. 18. Radiograph control with the prosthesis.
excellent mechanical properties for the stabilization of bone grafts under the membranes. It is rigid enough to favor space maintenance, to prevent contour collapse and to protect the blood clot from the overlying tissue and allow only bone promoting cells to repopulate the bone defects, its plasticity permits bending,
185
contouring and adaptation to define space below the mesh that mimics the shape of the desired alveolar ridge [7]. Louis et al. have proved that Ti-mesh maintains space with a higher degree of predictably, even in cases with a large bony cavity [8,9]. However, titanium mesh is not flexible as other membranes and this leads to an increased number of exposures [10]. Another factor that could contribute to the exposure is the cutting and the trimming of titanium mesh. The sharp edges and corners could cause the irritation of the mucosal flaps [11]. Although the high risk of exposure, Von Arx et al. noticed no infection despite exposure in any of his patients [12]. The smooth surface of this barrier makes it less susceptible to bacterial contamination and this may not require immediate removal [13]. Zitzmann et al. compared expanded polytetrafluoroethylene and titanium-reinforced ePTFE membranes to titanium mesh and declared that they has been frequently associated with complications such as exposure and infection leading to a compromised regenerative treatment outcome [14]. Selvig et al. (1990) and Nowzari and Slots (1995) indicate that the spongy architecture of resorbable membranes is a possible nidus for infection. These membranes are initially able to keep the space but they generally lose strength, collapse into the space and lead to a failed reconstruction [15,16]. Maiorana et al. showed that exposure of titanium mesh led to early graft resorption in the exposed area of about 15% to 25%, but did not cause any significant complications or interfere with implant placement [17]. Her et al. proposed a modification of the exposed titanium mesh to relieve all sharp angles and irregularities in order to minimize the trauma and discomfort resulting from contact of the mesh with the tongue, cheek and gingival [7]. Torres et al. have suggested that covering the titanium mesh with platelet-rich plasma was a determining factor in avoiding mesh exposure and graft failure [18]. Another common feature of commercially titanium mesh membrane is its macroporosity (in the millimeter range). It has been hypothesized that these macropores play a critical role in maintaining blood supply and allowing diffusion of extracellular nutrients across the membrane [19,20]. Previous studies have consistently found a layer of soft tissue interposed between the titanium mesh and the regenerated bone, it has been postulated that this layer might result from infiltration of non-osseous tissue into the defect. This soft tissue layer has been labeled a ‘‘pseudoperiosteum’’ by some authors [21–23]. The role of this layer may be the prevention of graft infection and resorption [24,25]. However, this makes the material difficult to remove at the second-stage surgery. Lizio et al. reported that, in several cases, the soft tissue was difficult to be removed without taking away part of the new regenerated bone [25]. Her et al. said that meshes with large pores ( 2 mm) resulted in the ingrowth of a greater volume of soft tissues than meshes with pores < 2 mm [7], while Gutta et al. found that macroporous mesh prevented significant soft tissue ingrowth and facilitated greater bone regeneration compared with microporous meshes (pore size 1.2 vs. 0.6 mm) [24].
4. Conclusion The use of rigid titanium occlusive screwed barrier with autogenous and bovine bone graft might be a reliable technique for alveolar ridge reconstruction. This approach achieves excellent final esthetic outcome of the implant-supported restoration. Exposure of the titanium mesh did not affect the success regenerative outcomes.
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
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Further studies should be done to adjust the pore size and the frequency in titanium mesh biomaterial to improve their efficacy in dental applications. Disclosure of interest The authors declare that they have no competing interest. References [1] Rakhmatia YD, Ayukawa Y, Furuhashi A, Koyano K. Current barrier membranes: titanium mesh and other membranes for guided bone regeneration in dental applications. J Prosthodont Res 2013;57:3–14. [2] Hammerle CH, Karring T. Guided bone regeneration at oral implant sites. Periodontol 1998;2000(17):151–75. [3] Scantlebury TV. 1982-1992: a decade of technology development for guided tissue regeneration. J Periodontol 1993;64:1129–37. [4] Boyne PJ, Cole MD, Stringer D, Shafqat JP. A technique for osseous restoration of deficient edentulous maxillary ridges. J Oral Maxillofac Surg 1985;43:87–91. [5] Wang HL, Al-Shammari K. HVC ridge deficiency classification: a therapeutically oriented classification. Int J Periodontics Restorative Dent 2002;22:335–43. [6] Hammerle CH, Jung RE, Feloutzis A. A systematic review of the survival of implants in bone sites augmented with barrier membranes (guided bone regeneration) in partially edentulous patients. J Clin Periodontol 2002;29:226–31. [7] Her S, Kang T, Fien MJ. Titanium mesh as an alternative to a membrane for ridge augmentation. J Oral Maxillofac Surg 2012;70:803–10. [8] Louis PJ, Gutta R, Said-Al-Naief N, Bartolucci AA. Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement. J Oral Maxillofac Surg 2008;66:235–45. [9] Louis PJ. Vertical ridge augmentation using titanium mesh. Oral Maxillofac Surg Clin North Am 2010;22:353–68. [10] Watzinger F, Luksch J, Millesi W. Guided bone regeneration with titanium membranes: a clinical study. Br J Oral Maxillofac Surg 2000;38:312–5. [11] Sumida T, Otawa N, Kamata YU, Kamakura S, Mtsushita T, Kitagaki H, et al. Custom-made titanium devices as membranes for bone augmentation in implant treatment: clinical application and the comparison with conventional titanium mesh. J Craniomaxillofac Surg 2015;43:2183–8. [12] Von Arx T, Hardt N, Wallkamm B, The TIME. technique: a new method for localized alveolar ridge augmentation prior to placement of dental implants. Int J Oral Maxillofac Implants 1996;11:387–94.
[13] Khanna R, Khanna R, Pardhe ND, Srivastava N, Bajpai M, Gupta S. Pure titanium membrane (Ultra-Ti1) in the treatment of periodontal osseous defects: a split-mouth comparative study. J Clin Diagn Res 2016;10(9):ZC47–51. [14] Zitzmann NU, Naef R, Scha¨rer P. Resorbable versus non-resorbable membranes in combination with bio-oss for guided bone regeneration. Int J Oral Maxillofac Implants 1997;12:844–52. [15] Selvig KA, Nilveus RE, Fitzmorris L, Kersten B, Khorsandi SS. Scanning electron microscopic observations of cell populations and bacterial contamination of membranes used for guided periodontal tissue regeneration in humans. J Periodontol 1990;61:515–20. [16] Nowzari H, Slots J. Microbiologic and clinical study of polytetrafluoroethylene membranes for guided bone regeneration around implants. Int J Oral Maxillofac Implants 1995;10:67–73. [17] Maiorana C, Santoro F, Rabagliati M, Salina S. Evaluation of the use of iliac cancellous bone and anorganic bovine bone in the reconstruction of the atrophic maxilla with titanium mesh: a clinical and histologic investigation. Int J Oral Maxillofac Implants 2001;16:427–32. [18] Torres J, Tamimi F, Alkhraisat MH, Mancho´n A, Linares R, Prados-Frutos JC, et al. Platelet-rich plasma may prevent titanium-mesh exposure in alveolar ridge augmentation with anorganic bovine bone. J Clin Periodontol 2010;37:943–51. [19] Linde A, Thoren C, Dahlin C, Sandberg E. Creation of new bone by an osteopromotive membrane technique: an experimental study in rats. Int J Oral Maxillofac Surg 1993;51:892–7. ˜ ones CR, Ohlms A, Caffesse RG. Contribution of the [20] Weng D, Hu¨rzeler MB, Quin periosteum to bone formation in guided bone regeneration. Clin Oral Implants Res 2000;11:546–54. [21] Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T. Alveolar ridge reconstruction with titanium mesh and autogenous particulate bone graft: computed tomography-based evaluations of augmented bone quality and quantity. Clin Impl Dent Relat Res 2012;14:304–11. [22] Pieri F, Corinaldesi G, Fini M, Aldini NN, Giardino R, Marchetti C. Alveolar ridge augmentation with titanium mesh and a combination of autogenous bone and anorganic bovine bone: a 2-year prospective study. J Periodontol 2008;79:2093–103. [23] Proussaefs P, Lozada J. Use of titanium mesh for staged localized alveolar ridge augmentation: clinical and histologic-histomorphometric evaluation. J Oral Implantol 2006;32:237–47. [24] Gutta R, Baker RA, Bartolucci AA, Louis PJ. Barrier membranes used for ridge augmentations: is there an optimal pore size? J Oral Maxillofac Surg 2009;67:1218–25. [25] Lizio G, Corinaldesi G, Marchetti C. Alveolar ridge reconstruction with titanium mesh: a three-dimensional evaluation of factors affecting the bone augmentation. Int J Oral Maxillofac Implants 2014;29:1354–63.
Available online at
ScienceDirect www.sciencedirect.com
Case Report
Ridge augmentation with titanium mesh: A case report H. Jegham *, R. Masmoudi, H. Ouertani, I. Blouza, S. Turki, M.B. Khattech Military Hospital, No 8, Univers street, Tunis, Tunisia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 October 2016 Accepted 16 March 2017 Available online 28 March 2017
Insufficient bone volume for dental implant placement in the maxillary anterior segment is a constant challenge in oral surgery. Several techniques have been suggested to reconstruct deficient alveolar ridges and to facilitate dental implant placement. These techniques include bone splitting osteotomy, distraction osteogenesis, inlay and onlay bone grafting. Guided bone regeneration (GBR) is also a promising alternative that increases the bone volume by the use of a subperiosteal barrier. Aim: The aim of this case was to demonstrate that the use of rigid titanium occlusive barrier is a reliable alternative to perform a lateral alveolar bone augmentation and treat localized ridge deformities before reaching an ideal implant placement. Observation: A 25-year-old healthy male was referred for implant placement in the maxillary central incisor. The alveolar bone width at the implant site 21 was less than 5 mm. Hard tissue augmentation was accomplished using guided bone regeneration. A rigid titanium occlusive barrier was customized to desired shape of future alveolar ridge then secured with tent and fixing screws. Autogenous bone graft harvested with an auto-chip-maker adjacent to the surgical site were mixed with a xenograft and putted under the barrier. The wound was closed using a vestibular mucoperiosteal flap. At 4 months, the rigid barrier was removed, and a 7 mm crestal width transversal bone was observed. At the same time, a fixture (4 10 mm) was placed. A definitive ceramometal crown was completed after full osseointegration with periodical clinical maintenance. The exposure of the titanium mesh occurred in this case and was visible with a circular flap dehiscence at 1-month follow-up visit. This exposure did not affect the successful regenerative outcomes. After removal of the titanium mesh from the grafted defects, the space beneath the membrane enclosure was seen to be almost completely filled with new hard tissue covered by a thin layer of soft tissue. The postoperative follow-ups revealed that the implant was stable with excellent osseointegration and the buccal depression of the surgical area was reconstructed. Conclusion: The use of rigid titanium occlusive screwed barrier with autogenous and bovine bone graft might be a reliable technique for alveolar ridge reconstruction. This approach achieve excellent final esthetic outcome of the implant-supported restoration. Published by Elsevier Masson SAS.
1. Introduction Insufficient bone volume for dental implant placement in the maxillary anterior segment leads to functional and esthetic problems and can be difficult to solve. Several techniques have been suggested to reconstruct deficient alveolar ridges and to facilitate dental implant placement. These techniques include bone splitting osteotomy, distraction osteogenesis, inlay and onlay bone grafting [1]. Guided bone regeneration (GBR) is also a promising alternative that increases the bone volume by the use of a subperiosteal barrier [2].
* Corresponding author. E-mail address: [email protected] (H. Jegham). http://dx.doi.org/10.1016/j.jormas.2017.03.001 2468-7855/Published by Elsevier Masson SAS.
Expanded polytetrafluoroethylen (ePTFE) was the first nonresorbable membrane proposed to allow spontaneous bone growth after the formation of a coagulum below the barrier and then permitting guided bone regeneration [3]. Besides, PTFE membrane, titanium mesh is another nonresorbable material used in multiple medical applications and, more recently, for dental bone repair. The use of titanium mesh was first introduced by Boyne in 1969, for the reconstruction of large osseous defects [4]. The stiffness of this membrane makes it easy to customize and to shape. Hence, the creation and the maintenance of a space for graft placement could prevent the collapse of the biomaterial and provide GBR. The aim of this case was to demonstrate that the use of rigid titanium occlusive barrier is a reliable alternative to perform a
182
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
lateral alveolar bone augmentation and treat localized ridge deformities before reaching an ideal implant placement.
2. Observation A 25-year-old healthy man was referred for implant placement in the maxillary central incisor. The patient reported a history of trauma and inadequate endodontic treatments leading to the loss of the tooth 21 (Figs. 1 and 2). The cone-beam reveals at the implant site horizontal bone resorption, the width of the alveolar ridge was less than 5 mm (class H-m according to Wang HVC classification [2002]) [5] (Fig. 3). Therefore, we decided to perform lateral bone augmentation before implant placement by the use of a titanium mesh for GBR. After reflection of a full thickness flap, a rigid titanium occlusive barrier (CTi-mem Type B, Neobiotech, Seoul, Korea) was trimmed and contoured to desired shape of future alveolar ridge, then secured with tent screws. Autogenous bone graft harvested with an auto-chip-maker (ACM, Neobiotech, Seoul, Korea) adjacent to the surgical site were mixed with a xenograft (Cerabone1, Biomaterials GmbH, Germany) and placed under the barrier. Next, fixing screw was used to secure the mesh and the bone graft material. The wound was closed using a buccal mucoperiosteal flap coronally repositioned (Figs. 4–9). The postoperative care includes use of antibiotic (amoxicillin 500 mg orally 3 times daily for 7 days) and an analgesic. Patient was instructed to rinse with chlorhexidine 0, 12% twice daily for 2 weeks. Sutures were removed 10 days after surgery. At 4 months of healing, the augmented site was reopened using a crestal incision. Once it is fully exposed, the rigid barrier was removed, and a 7 mm crestal width transversal bone was observed. At the same time, a fixture (4 10 mm, NeoCMI implant, Neobiotech, Seoul, South Korea) was placed. Six months later, we undertake the second time surgery and an adequate healing
Fig. 1. Preoperative view of the site.
Fig. 2. Occlusal view with vestibular tissue loss.
Fig. 3. Bone defect on site 11 observed on the cone beam.
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
183
Fig. 4. Full thickness flap elevation exposing a large horizontal defect.
abutment was screwed. Then, a definitive ceramometal crown was completed with periodical clinical maintenance. During the healing phase, a small circular flap dehiscence and exposure of the titanium mesh occurred and were visible at onemonth follow-up visit. In this case, there were no clinical signs of inflammation or infection. This exposure did not affect the successful regenerative outcomes. Patient was maintained on chlorhexidine gel until the time of mesh removal. He came in for weekly appointments for bacterial plaque control and to verify the status of the clinical healing (Fig. 10).
Fig. 7. The titanium mesh is trimmed and contoured to the desired shape of the future alveolar ridge.
Fig. 5. Decortication of the buccal plate to expose bone marrow.
Fig. 6. A tenting screw is putted on the top of the ridge.
Figs. 8 and 9. The space under the mesh is filled with a xenograft mixed with autogenous bone graft and then the mesh is fixed with a fixing screw.
184
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
Fig. 10. One month later, there is a circular shape exposure of the titanium mesh and the tenting screw without any signs of inflammation.
Fig. 13. A 4 mm diameter fixture is putted after ridge reconstruction.
3. Discussion At the reentry procedure, the titanium mesh appeared to be surrounded by tissues with little signs of clinical inflammation. The newly formed tissue under the mesh allows the placement of a 4mm 10 mm fixture. Implant site preparation revealed a regenerated hard tissue clinically consistent with alveolar bone. During implant osteotomy preparation, significant resistance was noted, the implant was then inserted with a primary stability of 40 N/cm (Figs. 11–13). The postoperative follow-up revealed that the implant was stable with excellent osseointegration and the buccal depression of the surgical area was reconstructed (Figs. 14–18).
Figs. 11 and 12. At reentry after six months, we remove the titanium mesh and the tenting screw. A high quantity of a newly regenerated tissue is observed.
Having an adequate bone volume is certainly an important prerequisite for a long-term implant success. Among the various techniques developed to increase bone volume, GBR and the use of bone grafting materials or combination of these two methods are reported as providing the best and the most predictable results [6]. Many factors contribute to successful GBR outcomes. Barriers membranes must fulfill a certain design criteria as described by Scantlebury such as biocompatibility, space making, cell occlusiveness, tissue integration and clinical manageability. Barriers membranes are grouped as resorbable and non-resorbable membranes [3]. Titanium mesh is non-resorbable membrane that has been extensively used in surgical dental application because of its
Figs. 14 and 15. Six months later, we start the second surgical time and a large diameter-healing abutment is connected.
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
Figs. 16 and 17. The definitive prostheses is cemented one month later with a good esthetic result.
Fig. 18. Radiograph control with the prosthesis.
excellent mechanical properties for the stabilization of bone grafts under the membranes. It is rigid enough to favor space maintenance, to prevent contour collapse and to protect the blood clot from the overlying tissue and allow only bone promoting cells to repopulate the bone defects, its plasticity permits bending,
185
contouring and adaptation to define space below the mesh that mimics the shape of the desired alveolar ridge [7]. Louis et al. have proved that Ti-mesh maintains space with a higher degree of predictably, even in cases with a large bony cavity [8,9]. However, titanium mesh is not flexible as other membranes and this leads to an increased number of exposures [10]. Another factor that could contribute to the exposure is the cutting and the trimming of titanium mesh. The sharp edges and corners could cause the irritation of the mucosal flaps [11]. Although the high risk of exposure, Von Arx et al. noticed no infection despite exposure in any of his patients [12]. The smooth surface of this barrier makes it less susceptible to bacterial contamination and this may not require immediate removal [13]. Zitzmann et al. compared expanded polytetrafluoroethylene and titanium-reinforced ePTFE membranes to titanium mesh and declared that they has been frequently associated with complications such as exposure and infection leading to a compromised regenerative treatment outcome [14]. Selvig et al. (1990) and Nowzari and Slots (1995) indicate that the spongy architecture of resorbable membranes is a possible nidus for infection. These membranes are initially able to keep the space but they generally lose strength, collapse into the space and lead to a failed reconstruction [15,16]. Maiorana et al. showed that exposure of titanium mesh led to early graft resorption in the exposed area of about 15% to 25%, but did not cause any significant complications or interfere with implant placement [17]. Her et al. proposed a modification of the exposed titanium mesh to relieve all sharp angles and irregularities in order to minimize the trauma and discomfort resulting from contact of the mesh with the tongue, cheek and gingival [7]. Torres et al. have suggested that covering the titanium mesh with platelet-rich plasma was a determining factor in avoiding mesh exposure and graft failure [18]. Another common feature of commercially titanium mesh membrane is its macroporosity (in the millimeter range). It has been hypothesized that these macropores play a critical role in maintaining blood supply and allowing diffusion of extracellular nutrients across the membrane [19,20]. Previous studies have consistently found a layer of soft tissue interposed between the titanium mesh and the regenerated bone, it has been postulated that this layer might result from infiltration of non-osseous tissue into the defect. This soft tissue layer has been labeled a ‘‘pseudoperiosteum’’ by some authors [21–23]. The role of this layer may be the prevention of graft infection and resorption [24,25]. However, this makes the material difficult to remove at the second-stage surgery. Lizio et al. reported that, in several cases, the soft tissue was difficult to be removed without taking away part of the new regenerated bone [25]. Her et al. said that meshes with large pores ( 2 mm) resulted in the ingrowth of a greater volume of soft tissues than meshes with pores < 2 mm [7], while Gutta et al. found that macroporous mesh prevented significant soft tissue ingrowth and facilitated greater bone regeneration compared with microporous meshes (pore size 1.2 vs. 0.6 mm) [24].
4. Conclusion The use of rigid titanium occlusive screwed barrier with autogenous and bovine bone graft might be a reliable technique for alveolar ridge reconstruction. This approach achieves excellent final esthetic outcome of the implant-supported restoration. Exposure of the titanium mesh did not affect the success regenerative outcomes.
H. Jegham et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 181–186
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Further studies should be done to adjust the pore size and the frequency in titanium mesh biomaterial to improve their efficacy in dental applications. Disclosure of interest The authors declare that they have no competing interest. References [1] Rakhmatia YD, Ayukawa Y, Furuhashi A, Koyano K. Current barrier membranes: titanium mesh and other membranes for guided bone regeneration in dental applications. J Prosthodont Res 2013;57:3–14. [2] Hammerle CH, Karring T. Guided bone regeneration at oral implant sites. Periodontol 1998;2000(17):151–75. [3] Scantlebury TV. 1982-1992: a decade of technology development for guided tissue regeneration. J Periodontol 1993;64:1129–37. [4] Boyne PJ, Cole MD, Stringer D, Shafqat JP. A technique for osseous restoration of deficient edentulous maxillary ridges. J Oral Maxillofac Surg 1985;43:87–91. [5] Wang HL, Al-Shammari K. HVC ridge deficiency classification: a therapeutically oriented classification. Int J Periodontics Restorative Dent 2002;22:335–43. [6] Hammerle CH, Jung RE, Feloutzis A. A systematic review of the survival of implants in bone sites augmented with barrier membranes (guided bone regeneration) in partially edentulous patients. J Clin Periodontol 2002;29:226–31. [7] Her S, Kang T, Fien MJ. Titanium mesh as an alternative to a membrane for ridge augmentation. J Oral Maxillofac Surg 2012;70:803–10. [8] Louis PJ, Gutta R, Said-Al-Naief N, Bartolucci AA. Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement. J Oral Maxillofac Surg 2008;66:235–45. [9] Louis PJ. Vertical ridge augmentation using titanium mesh. Oral Maxillofac Surg Clin North Am 2010;22:353–68. [10] Watzinger F, Luksch J, Millesi W. Guided bone regeneration with titanium membranes: a clinical study. Br J Oral Maxillofac Surg 2000;38:312–5. [11] Sumida T, Otawa N, Kamata YU, Kamakura S, Mtsushita T, Kitagaki H, et al. Custom-made titanium devices as membranes for bone augmentation in implant treatment: clinical application and the comparison with conventional titanium mesh. J Craniomaxillofac Surg 2015;43:2183–8. [12] Von Arx T, Hardt N, Wallkamm B, The TIME. technique: a new method for localized alveolar ridge augmentation prior to placement of dental implants. Int J Oral Maxillofac Implants 1996;11:387–94.
[13] Khanna R, Khanna R, Pardhe ND, Srivastava N, Bajpai M, Gupta S. Pure titanium membrane (Ultra-Ti1) in the treatment of periodontal osseous defects: a split-mouth comparative study. J Clin Diagn Res 2016;10(9):ZC47–51. [14] Zitzmann NU, Naef R, Scha¨rer P. Resorbable versus non-resorbable membranes in combination with bio-oss for guided bone regeneration. Int J Oral Maxillofac Implants 1997;12:844–52. [15] Selvig KA, Nilveus RE, Fitzmorris L, Kersten B, Khorsandi SS. Scanning electron microscopic observations of cell populations and bacterial contamination of membranes used for guided periodontal tissue regeneration in humans. J Periodontol 1990;61:515–20. [16] Nowzari H, Slots J. Microbiologic and clinical study of polytetrafluoroethylene membranes for guided bone regeneration around implants. Int J Oral Maxillofac Implants 1995;10:67–73. [17] Maiorana C, Santoro F, Rabagliati M, Salina S. Evaluation of the use of iliac cancellous bone and anorganic bovine bone in the reconstruction of the atrophic maxilla with titanium mesh: a clinical and histologic investigation. Int J Oral Maxillofac Implants 2001;16:427–32. [18] Torres J, Tamimi F, Alkhraisat MH, Mancho´n A, Linares R, Prados-Frutos JC, et al. Platelet-rich plasma may prevent titanium-mesh exposure in alveolar ridge augmentation with anorganic bovine bone. J Clin Periodontol 2010;37:943–51. [19] Linde A, Thoren C, Dahlin C, Sandberg E. Creation of new bone by an osteopromotive membrane technique: an experimental study in rats. Int J Oral Maxillofac Surg 1993;51:892–7. ˜ ones CR, Ohlms A, Caffesse RG. Contribution of the [20] Weng D, Hu¨rzeler MB, Quin periosteum to bone formation in guided bone regeneration. Clin Oral Implants Res 2000;11:546–54. [21] Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T. Alveolar ridge reconstruction with titanium mesh and autogenous particulate bone graft: computed tomography-based evaluations of augmented bone quality and quantity. Clin Impl Dent Relat Res 2012;14:304–11. [22] Pieri F, Corinaldesi G, Fini M, Aldini NN, Giardino R, Marchetti C. Alveolar ridge augmentation with titanium mesh and a combination of autogenous bone and anorganic bovine bone: a 2-year prospective study. J Periodontol 2008;79:2093–103. [23] Proussaefs P, Lozada J. Use of titanium mesh for staged localized alveolar ridge augmentation: clinical and histologic-histomorphometric evaluation. J Oral Implantol 2006;32:237–47. [24] Gutta R, Baker RA, Bartolucci AA, Louis PJ. Barrier membranes used for ridge augmentations: is there an optimal pore size? J Oral Maxillofac Surg 2009;67:1218–25. [25] Lizio G, Corinaldesi G, Marchetti C. Alveolar ridge reconstruction with titanium mesh: a three-dimensional evaluation of factors affecting the bone augmentation. Int J Oral Maxillofac Implants 2014;29:1354–63.