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Regeneration of Lost Architecture in the Maxilla

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Regeneration of Lost Architecture in the Maxilla -Dr. Stephanie Cruz and Dr. Edgard El Chaar 

Introduction

Guided bone regeneration (GBR) procedures are necessary when there is an inadequate amount of bone volume in width and/or height for implant placement.  There are a variety of procedures and grafting materials that can be utilized in ridge augmentations.  In 2011, Fu and Wang (1) created a decision tree based on the residual ridge width.  Titanium mesh has been well documented in the literature as an effective means to increase an edentulous ridge vertically and horizontally. (2,3,4) Clinicians may not prefer to use titanium mesh due to its handling properties.  The use of a 3-D  model can aid in treatment planning, patient education, and creating a surgical template. The following is a case presentation of a patient who presented in the department of periodontology at New York University.  The patient is a 28 year old male who has a vertical and horizontal ridge deficiency in the upper right maxilla. 

Objective

To demonstrate the clinical and histological healing of a GBR procedure using titanium mesh and 100% allograft using a 3-D printed model.  The soft tissue around the implants placed was also enhanced using an acellular dermal matrix.


Methods

 Due to the deficiency the patient presented with, multiple surgeries were necessary.  Prior to any surgical intervention, a pre-operative CT scan was obtained to determine the amount of ridge augmentation necessary.  The pre-operative CT scan demonstrates the mean width of 4.23 mm.  From the CT scan, a 3-D printed model was constructed.  The 3-D model was used to construct the titanium mesh to the appropriate size to regenerate the lost architecture.  The titanium mesh was adapted to the appropriate size and sterilized prior to surgery.   A full thickness flap was raised and the titanium mesh was fixed in place.  A combination of cortical and cancellous allograft was placed beneath the mesh.  Primary closure was obtained and the patient was monitored on a monthly basis.  After 6 months, a post-operative CT scan was taken to determine implant placement and the amount of bone gain. 

Two implants were placed  and a bone core sample was taken to examine the histology.  Three months after implant placement, an acellular dermal matrix (ADM) was tacked in place on the buccal side and healing abutments were placed. To create a papilla between the healing abutments, a rotated pediculated lingual marginal tissue was used (5).  After 3 weeks, a vestibuloplasty was completed using an Er: YAG laser.

Results

The 6 month post-op CBCT scan revealed an increased width an average of 5.39 mm and increased vertical height to 15.04 mm.  The histological sample taken at the time of implant placement revealed viable bone around the allograft particles. The use of the ADM helped increase the amount of keratinized gingiva and the rotated pediuclate lingual graft created inter proximal papilla between the healing abutments


Conclusions/Summary

In order to reconstruct a discrepancy in hard and soft tissue, multiple procedures are necessary.  By taking a pre-operative CT scan in order to construct a 3-D model will allow the clinician to understand how much grafting is necessary and create a template for surgery.  Titanium mesh using 100% allograft is a viable option for patients.  Additionally, soft tissue augmentation is necessary to increase the width of keratinized tissue.  

Acknowledgement

We would like to thank Dr. A. Brian Urtula for his help in creating the 3-D model

References

  1. Fu, J. H., & Wang, H. L. Horizontal bone augmentation: the decision tree. Int J Perio and Restorative Dent, 2011; 31:429-436.
  2. Artzi Z et al. Vertical ridge augmentation using titanium mesh with xenogenic material: Clinico-histopathologic and histochemical study. IJOMI 2003;18:440-446
  3. Proussaefs, P, Lozada J. Use of titanium mesh for staged localized alveolar ridge augmentation: Clinical and histologic-histomorphometric evaluation. J. Oral Implantol 2006;32:237-247
  4. Roccuzzo M, Ramieri G, Bunino M, Berrone S. Autogenous bone graft alone or associated with titanium mesh for vertical alveolar ridge augmentation: A controlled clinical trial. Clin Oral Implants Res 2007;18: 286-294.
  5. El Chaar, E and Oshman, S.  “Techniques of Soft Tissue Grafting in Implant Dentistry”  Horizontal Alveolar Ridge Augmentation in Implant Dentistry: A Surgical Manual. Hoboken, NJ: John Wiley & Sons. Ed. Len Tolstunow.  2016






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